Low arousal approach in dental care

Autism spectrum disorder, ADHD and Tourette's syndrome are all examples of neurodevelopmental disorders (NDD). It is also common to have a language disorder linked to the diagnosis. NDD means that the brain works in a different way. We can all forget an appointment or find it difficult to concentrate at times. It is only when these difficulties become so overwhelming that they significantly affect the individual's development and ability to function in society that it becomes a disability.

People with NDD have varying difficulties in areas such as:

• Attention control
• Impulse control and activity level
• Interaction with other people
• Learning and memory
• Speaking and writing skills
• Fine and gross motor skills

These symptoms can make it difficult for individuals to brush their teeth or to cooperate during a dental care visit. The majority of children and adolescents with NDD therefore need additional preventative dental care. If you would like to learn more about dentistry and NDD, we recommend that you read our Oral care program for individuals with NDD.

Oral care program for individuals with NDD

As a dental professional, you may have personally experienced a visit with a child or adolescent with NDD who behaved in a different and unexpected manner. Perhaps it was difficult for the patient to even enter the clinic or the examination room. Perhaps the visit ended in an anger-filled conflict?

A low arousal approach aims to prevent and manage strong emotional expressions. The concept was introduced and further developed in Sweden by Bo Heijlskov Elvén, a psychologist who has a long history of working with people with NDD himself. A low arousal approach seeks to provide the tools to manage conflicts without confrontation in a manner that is both ethical and defensible. A good example of a low arousal approach was depicted in Astrid Lindgren's book Emil of Lönneberga in the farmhand Alfred through his calm demeanor, which stood in strong contrast to Emil's father Anton, who usually showed a very high level of arousal and strong emotions when he yelled "EEEEEMIL, you horrid child!"

Too much emotion can easily cause you to lose control of yourself and fall into a state of chaos. If people are aware of how emotions can be "infectious", both verbally and through body language, a proper approach may then reduce or deflect an emotional outburst and thereby help an individual to maintain their self-control. The purpose is to "infect" them with your calmness and thus avoiding a chaotic scenario. You must therefore take responsibility for both your own emotional state as well as that of the recipient.

It is important that the entire dental team is aware of the fact that emotions can be infectious and that they are able to regulate and control their own emotional states.

What is a challenging behavior?

Challenging behavior can be defined as a behavior that not only disrupts the individual, but most often the environment around them as well. In short, it is not the individual who is the cause of this disruption, but rather all the different situations and approaches that together may create an anxious situation.

Those who take responsibility have influence

It is of utmost importance that we as dental professionals are informed and show a positive attitude when we meet patients with an NDD diagnosis. By adapting our approach to the patient's mood and by making reasonable demands in our treatment, we are able to help the patient manage their emotions and thereby maintain self-control and avoid challenging behavior. 

"Change of thought" – looking at the situation from a different perspective

There are usually two common assumptions that:

• We believe the person is doing something wrong and should be corrected.
• We believe that the person is doing their best and should be supported.

The process of going from one basic assumption to another is what we would like to call a "change of thought".

Another example of a change of thought:

They can but they won't. ► They want to but they can't.

Understanding the patient becomes completely different if you approach them with the belief that "they want to, but they can't (or don't understand)."

If we think that other people think and act same way as we do, it makes it easy for us to think that the person with NDD is causing problems on purpose. That is us moralizing and putting all the responsibility on the individual. In moments such as these, we risk:

• Not being curious about why they act the way they do
• Not feeling empathy
• Think less of the person
• Reducing our flexibility and acceptance
• Not adapting ourselves or taking personal responsibility

We also run the risk of increasing the individual's stress levels, causing them to lose their self-control and fall into a state of chaos.

Instead, if we consider the person as vulnerable, we are able to approach them both ethically and responsibly. Then we can:

• Be curious about why they act the way they do
• Be empathetic
• Like the person more
• Be more flexible and accepting
• Adapt and take shared responsibility

The individual is also more likely to maintain their self-control. We take responsibility for both our own emotional state and that of the recipient.

Our task in dentistry is to find different tools to empower the patient. Shifting perspectives can be an important means of enabling patients to participate in the care we strive to provide.

A low arousal approach could lead to effects and outcomes for the patient such as:

• Being seen
• Succeeding personally
• Developing their self-esteem by overcoming difficult situations
• Reducing difficulties
• Finding common and workable tools for success

Making the right demands

Emotional "explosions" are usually preceded by excessive demands. The demands we make, both on others and on ourselves, can be influenced. As practitioners, we need to take responsibility for making demands at a level that the patient is able to cope with. You have to be in control of yourself for a successful cooperation. We can use various means to help the patient maintain their self-control. But in order for us to do this, we need to be in control of our own behavior and emotions. It is also important to remember that everyone wants to succeed. If we can work together, we will.

Bo Hejlskov Elvén, psychologist

Dentistry requires trust. There are few situations in life where we are as vulnerable as when we are in the dental office, lying down (we only lie down in safe contexts), with one of the most sensitive parts of our body (the mouth) fully exposed, all the while having the dental professionals' fingers in our mouths. Add to this that some dental care is also associated with pain. We put ourselves in this situation that violates our privacy completely voluntarily. We do this because most of us understand the situation, that all this is necessary to avoid toothaches, eating difficulties and more serious health problems in the long term. It therefore serves a purpose.

Purpose is an important reason why we do what we do. Actions should serve a purpose if we are to do them on our own accord; we are all motivated to do things that has a purpose. We can see motivation as a result of purpose; we are motivated by what serves a purpose but lack motivation by that which lack purpose. What gives purpose is different for each of us. We often describe purpose in terms of understanding: if we understand why, then it has a purpose. Most of us understand on an intellectual level why we should exercise, abstain from fatty foods, tobacco and alcohol, yet we still live unhealthy lives. Those who succeed in healthy living do so not only because they understand; they often find that the practice itself has a purpose. This is where dentistry stands out. Few people see the dental visit interesting in itself. We feel it is a necessary evil, but we can justify it because we know it is good for us. The dental care service even needs to send text message reminders and use other tools to motivate us to go there.

People with intellectual disabilities and/or NDD may have difficulties understanding cause and effect in complex contexts. This creates problems understanding concepts such as "why" and "because". It may therefore make it difficult to use preunderstanding to increase motivation and to see the purpose of dental care.

An additional dilemma is the vulnerable situation they are in. People with intellectual disabilities and/or NDD have difficulty predicting what will happen due to a lack of understanding of cause and effect in complex contexts. It can be very difficult to understand why I was chosen to be in the dentist's chair and how long it will take, or how much it will hurt. The same fundamental difficulty also means that it is difficult to figure out the intentions of others. What do the dentistry staff want? Why are they doing this to me?

The perceptual sensitivity of many people with intellectual disabilities and/or NDD means that their pain thresholds may be low, sensitivity to pressure in the mouth and taste may be high (or too low), and the ability to tolerate sensory input may be limited.

The overall dental care visit is challenging, and the person often feels that they are vulnerable and unsafe. It can be difficult to grasp the situation, to get a clear picture and to organize the order of the events that are happening. The impressions can become overwhelming and it may hurt. Situations such as this calls for cooperation, so it is no wonder it can be difficult. The mission of dentistry is not just about dental care, but about creating trust and reassurance despite being faced with the most difficult circumstances that we can think of.

Special education strategies

In order to provide dental care for people with intellectual disabilities and/or NDD, the individual should have a sense of control over the situation. We can achieve this through various methods:

Time: More time should be set aside. A stressful situation increases the risk of failing a treatment.

Preparations: Visual support before the visit. Sending pictures of the reception, waiting room, treatment room and the practitioner in advance makes everything more predictable.

Quiet environment: In waiting rooms and treatment rooms.

Small steps: The first visit may just involve getting acquainted with the environment and the practitioner. Some may need many small steps, others fewer. But it should be up to the patient to decide what steps to take.

Calm approach: The practitioner should take the time to talk to the patient about their life-world before treatment begins.

Low arousal approach: Maintain calm throughout treatment even if the patient reacts with resistance, swearing, acting out or other behaviors we usually react to.

Visual supports during treatment: Use visual supports during treatment. Make it visibly clear to the patient by showing each step of the procedure with a corresponding image. Remove each image when the step is complete.

Information: Tell or show with pictures what will happen next. It is not enough to simply have visual support available before the treatment begins. You also need to describe what different things might feel and sound like.

Pausing: If the patient is feeling stressed, you can pause the treatment for a while.

Sensory aids: Offer something to fiddle with or hold onto. There are a variety of sensory aids that can have a calming effect.

Humor: Try to keep a jovial tone and a twinkle in your eye. Adapt your sense of humor to the patient's ability. Remember that almost everyone can joke. Humor is disarming and reduces both anxiety and stress.

Plan B: Having the option to back out allows us to feel safe in unpredictable situations.

Involvement: Evaluate together with the patient, if they are able to. What worked well and what needs to be done differently for the next visit. The goal of the evaluation is to increase the patient's sense of control over the situation. There are specific evaluation methods for people with communication disabilities, such as rating scales.

Remember...

... that the visit to the dentist may be one of the most difficult tasks in that individual's life. You also need to remember that they are doing their best to cooperate. That is why we too should do our best to cooperate. And not least, to make the whole process as safe as possible.

There are three basic pedagogical principles for a low arousal approach in dentistry:

1. The principle of responsibility – Those who take responsibility have influence

In order to create change, you need to accept and take personal responsibility and not resort to thinking that challenging behavior is the fault of the individual. Instead, begin by looking at what you can do to influence the situation. The aim is not to take control of the individual, but for them to maintain their self-control. This is not achieved by using dominance and discipline. People who find it difficult to cooperate have not been given the chance to live up to our demands and expectations. Adapting the framework creates the conditions for cooperation during the dental care visit. A low arousal approach is about leading through collaboration without being authoritarian.

From theory to practice: see patient case Nelly.

2. The principle of control – Strategies on how to avoid making things worse and more difficult

You have to be in control of yourself to be able to successfully cooperate with others. When the child exhibits a behavior that we do not want, we usually react by wanting to take control. What happens then is that the child loses their own self-control. A child who loses their self-control may experience a heightened affect intensity, resulting in them getting very angry, throwing things and so on.

Examples of situations in which a child may experience a heightened affect intensity are:

• When excessive demands are placed on them
• When children do not understand what we want or what is expected of them
• Sudden noises which can be disturbing
• Sudden changes to a routine which can cause anxiety

It is our job as dental professionals to help those we meet to maintain or regain their self-control. During treatment, we need to ensure that the child has the opportunity to feel in control, that they understand the situation, that they have a say and are listened to. Because the more self-control the child has in the situation, the more likely they are to cooperate.

From theory to practice: see patient case Lisa.

When the situation becomes difficult, use the principle of control:

• Calm approach
• Clarity – What we should do, such as taking a break.
• Avoid getting into a conflict – back off, wait and then return.
• Deflect – Provide clear alternatives
• Repeat everything again

3. The principle of affect contagion and mirror processes

A part of social interaction is that we reflect each other's feelings. This can be described as "affect contagion". Affect contagion means that emotional states tend to spread to others in our environment, through what is called mirror processes. What this means is that if you, as a practitioner, feel stressed and irritated, the patient will sense this and be the recipient of an affect contagion. The patient may even react more strongly to the feeling. A dominant body language in the practitioner can increase the sense of threat and stress in the individual, as well as risk making them aggressive. We should pay extra attention to our own feelings as practitioners! We should stay calm and relaxed even in chaotic situations, and infect patients with feelings of calmness and safety instead.

From theory to practice: see patient case William.

Things to consider to avoid challenging situations

It is important to understand that in this case it is not a question of lowering the standards of treatment, but rather adapting the standards to ensure that the individual understands the course of events. The basic idea is that it is easier to understand and follow things that feel comprehensible and transparent.

We have already mentioned the importance of keeping yourself calm, but you can also be more actively calm.

Here are some examples:

• Soften your emotional expressions, speak soothingly, in other words speak calmly without pretense or raising your voice. Think about your body language and position in relation to the child. Avoid pointing things out with tense physical movements. It is also a good idea to sit down if you notice that the child is getting worked up and stressed. Try also to understand the relationship between the child and the person accompanying them, so that they too can be a positive support during the treatment.
• Avoid "dominance tactics" such as staring, blocking or restraining them.
• Avoid dominating eye contact. A good way to do this is to avoid eye contact for more than three seconds and especially so in demanding situations. Eye contact increases affect contagion. Avoid standing directly in front of them, stand a little to the side instead. As dentistry professionals, we have an advantage in that our patients sit or lie in the treatment chair while we sit next to them, making it easier for us to talk to them without making direct eye contact if the situation calls for it.

Back off, wait and then return!

Backing off and respecting personal space matters. If the individual is upset, take a step back to relieve the pressure a bit.

Wait and give them plenty of time, do not rush. Wait for them to calm down and give them time to regain their self-control.

Then return to them and maintain your low arousal approach. If necessary, help the patient by making them think about other things (deflect). This can reduce stress.

Using this approach means that we have a good starting point for success!

What to do if conflict still occurs

The psychologist Ross W Greene coined the term "the basket model" in his book. The model provides three different strategies for dealing with conflicts. We sort the child's behavior and how we might respond to it in the three baskets. The model is designed to help us know how to evaluate and act in different types of conflict situations.

The child's behavior

Basket A – where you put dangerous behavior. That is, things that could harm the child, such as grabbing a sharp instrument. It must be severe enough to start and sustain a tantrum.

Basket B – where you put problem solving. These are problems that the adult and the child can solve together. The aim is for the adult to listen, guide and teach the child skills to avoid it happening again.

Basket C – where we put a "time out". This is when you take a pause, you don't give in but come back at a better time.

NO Basket

You decide immediately. You do not change your mind and you are prepared for an outburst.

Solve, explain and learn Basket

Explain, listen, argue, discuss and solve together. Time, opportunity and energy.

Let it go Basket

Let go of the situation. Do not take the conflict. You will deal with it some other day.

Diagnosis: Neuropsychiatric disability (Tourette's syndrome, OCD)

Communication: She speaks but her speech is often very fast and "forced"

Treatment: personalised acclimatisation to the dental care environment

Background: Lisa has found it very difficult to go to the dentist for several years and has often refused to cooperate. A personalised acclimatisation to the dental care environment is therefore initiated.

Preparing for a visit: The practitioner has an initial conversation on the phone with Lisa's father, who says that Lisa has considerable tics, both vocal and physical, and that new compulsions gradually emerge. The tics come as intense bodily jerks that can also take the form of kicks and punches. Lisa often curses and spits a lot. She can also say derogatory things to anyone, such as telling a stranger on the bus that they are ugly and fat.

Lisa is currently fixated on a roller bag that has to go everywhere with her, she opens and closes it constantly. Lisa has many rituals around dressing and she is sensitive to certain materials. Lisa is sensitive to light and often wears sunglasses. Dealing with food is difficult and her diet is one-sided. Hamburgers and soft drinks are the only things she accepts at the moment.

During the conversation, it is revealed that her mother has a deep fear of dentistry. It is therefore decided that Lisa's father will always accompany her to the visits. The idea is to reduce the risk of the mother transferring her own bad experiences (affect contagion) to her daughter. The practitioner stresses that it is important that the practitioner and the person accompanying the patient work together as a team to create a sense of continuity and safety. Together they also decide that the practitioner will give Lisa a small gift after each visit and that Lisa and her father will go out for a hamburger afterwards.

Settling-in period plan: It is recommended that Lisa and her father make a couple of trips to the clinic to get acquainted with the road there and the surroundings. Once Lisa feels comfortable with this, an appointment is made for a first visit. The father does not believe that Lisa wants visual supports before the visit at first, but he agrees eventually upon which photos are sent of the clinic and the practitioner. The first visit is only a meet-and-greet with the practitioner.

Visit 1

Lisa arrives at the clinic with her father, she is wearing sunglasses. Lisa is noisy and anxious in the waiting room, she is throwing and pulling her roller bag around, bumping into the furniture and magazine racks which causes the magazines to fall to the floor.

The practitioner rushes in and sees Lisa spitting. The situation takes the practitioner by surprise and makes her lose her temper. The practitioner raises her voice and tells Lisa firmly to stop throwing her roller bag around. The practitioner exclaims: "stop yelling, you're bothering the others! And you're absolutely not allowed to spit, that's disgusting."

Lisa's father thrusts her into the treatment room. Lisa is stressed and worried and tries to get out. The practitioner stands in the way and tells her sternly to listen and calm down. In frustration, Lisa rushes out of the treatment room and out of the clinic. Lisa disappears down the street, upset, with her father running after her.

Evaluation

How could the practitioner have acted differently by using a low arousal approach? It would have been wise to decide before the visit that the practitioner would meet her in the waiting room or to wait a while until Lisa had taken in the atmosphere there.

The practitioner became shocked by Lisa's behavior. It is important for the practitioner to be aware of their own emotions and try to "infect" Lisa with their calm demeanor next time. Lisa's behavior may be a strategy to not lose her self-control. She is doing her best. The practitioner should therefore ignore her behavior.

The situation was so demanding that Lisa lost her self-control. Self-control is the foundation for cooperation. The practitioner should have sensed the situation, backed off, waited and then returned once the situation had calmed down (the principle of control). It would have been preferable if the practitioner could have managed the visit by being collaborative rather than authoritarian.

After the visit, the father is contacted to talk about his and Lisa's experience, what happened and how Lisa reacted afterwards. They then draw up a strategy together for future visits.

Visit 2

Lisa arrives with her father to the clinic late one afternoon when the clinic has no other patients waiting. The practitioner meets them at the entrance outside and everyone goes together to the waiting room.

The father and the practitioner sit on the couch and chat, giving Lisa the time she needs to settle down in the waiting room. Lisa is very anxious during all this. She expresses both physical and verbal tics, while also spitting and cursing. These are ignored completely by the practitioner and Lisa's father. Lisa walks quickly and intensely back and forth with her large rolling bag, pulling, throwing and running into furniture, opening and closing the bag sporadically. She flails, kicks, spits and repeatedly takes her sunglasses on and off.

After a while, Lisa calms down and wants to show the practitioner what's in her bag. The practitioner, who has up to this point stood in the background, now shows interest in what Lisa is doing, and together they look at the things in her bag. Lisa is happy to show her things but continues to spit. Afterwards Lisa says she's sorry.

When Lisa is ready, they go into the treatment room to take a look around. The practitioner shows her the light and how the chair can go up and down and asks Lisa if she wants to try it. Lisa tries it and spits on the floor.

The practitioner praises Lisa for today's visit and gives her a small gift, which they put in her rolling bag together. Lisa leaves the clinic happy and satisfied, her father has promised that they will go for hamburgers as a reward.

Visit 3

Lisa arrives with her father. The practitioner has set aside plenty of time and is calm. She meets Lisa in the waiting room. Lisa performs the same rituals as she did during the last visit.

After a while, they go together into the treatment room where Lisa gets to take in the environment and raise and lower the dentist chair. Lisa sits down and holds a "tangle"-type of fidget toy to keep her hands busy. It has a calming effect. The practitioner puts a weighted pillow over Lisa's chest to dampen her bodily tics and gives her a cup to spit into. Through this approach and these tools, Lisa gains both bodily control and an opportunity for self-control.

After much praise and a small gift, Lisa leaves the clinic happy and satisfied.

Future visits

Repeated in the same way, adding new elements gradually. Lisa's endurance during treatment increases after each visit. The tics become fewer and less intense, and the spitting decreases as Lisa's self-control and confidence increase.

Diagnosis: Neuropsychiatric disability (Autism and ADHD)

Communication: Verbal, but speaks fast and loud which often makes his speech incoherent. Uses pictures and signs as support.

Treatment: Personalised acclimatisation to the dental care environment

Preparing for a visit: During a telephone conversation with the parents, William's mother says that new contacts with the healthcare system are usually difficult for William. He often speaks quickly and loudly, which can make his speech seem incoherent. His mother describes William as a very happy but restless and eager boy who loves music. William has difficulty being still and has difficulties with "inner speech" and thinking. William is also very impulsive.

As a reward after each visit, it is decided in consultation with his mother that William can choose something from our gift box and get more screen time at home.

Settling-in period plan: Visits to the clinic should be short and supplemented with detailed visual supports.

Visit 1

William arrives at the clinic with his mother ahead of schedule. It turns out that the practitioner is running late. All this means that William has to wait longer than he can handle. William becomes restless, noisy and bored in the waiting room. When his mother tells him to sit still, he gets very angry. The practitioner arrives, stressed and breathless, and welcomes William into the treatment room. William notices this and is "infected" by the stress of the practitioner (affect contagion).

In the treatment room, William runs around, pulling drawers and opening cabinets, while asking lots of questions about what the things are for. The practitioner tries to answer but is not able to keep up with Williams’ questions. William repeatedly asks what will happen next. He throws down the visual support that sits on the bulletin board.

William finally sits down in the treatment chair and the practitioner asks him to take off his cap. William refuses. The practitioner explains that it is important that he takes off his cap so that it is not in the way of the treatment and that she can look him in the eye. When William continues to refuse, the practitioner tries to physically remove his cap, but to no avail as he quickly backs away. William now consistently refuses to cooperate. The practitioner loses her patience and tells him to pull himself together and to look her in the eye when she is talking with him.

The atmosphere in the treatment room escalates and they both become increasingly irritated. William has had enough and sets out to leave the room. His mother tries to calm him down, but the situation cannot be saved. William and his mother leave the clinic.

Evaluation

How could the practitioner have acted differently by using a low arousal approach? Waiting can be a stressor that causes anxiety and frustration, which can result in a lowered trust and confidence. It is important that the practitioner keeps the time. The practitioner should have planned the visit in a manner that would not have made it stressful.

Even when William entered the treatment room, the situation was already stressful and hectic. This made him anxious and out of control in regards to what was expected of him. As a result, he could no longer cooperate. The practitioner could have used the principle of control in order to avoid making the situation more difficult for William. Children with developmental difficulties are more likely than others to run away in difficult situations when they lose their self-control. Things would probably have gone better if they had validated William's feelings by speaking calmly and telling him: "I can see you're upset, this didn't turn out the way you thought it would". The cap is an aid for William. It blocks impressions and provides a sense of security. This need must respected more.

The practitioner should not dominate by being assertive in their voice, body language or facial expressions, nor should they give ultimatums or pressure the patient. Instead, the practitioner should ensure that the patient always has a way out if the situation becomes demanding to the point where the patient cannot control it. Try to see the situation from the other person's perspective (do a change of thought). The practitioner should step back and suggest a break to calm the situation down and then return later (back off, wait, and then return). Doing this changes the demands.

After the visit, the mother is contacted to talk about her and Williams' view of the experience. She says they arrived too early for the visit. As the practitioner was late, they had to wait for a long time in a crowded waiting room. This caused William to lose focus. It was also clear that it is better for William to come to the clinic in the morning when his medication is working optimally. The visual support sent home before the visit had too many steps.

It is important to remember that William should not have to wait, and that he is sent home with a clear visual support with fewer steps. This provides him a sense of safety and self-control.

Visit 2

William and his mother arrive in the morning and are called in at the appointed time. The practitioner's approach is relaxed and his calm demeanor is infectious (affect contagion). Together they go through the visual support that shows the sequence of events of the visit. William proudly says that he has gone over it many times at home. During this visit, William is also offered headphones to listen to his favorite music.

Together, William and the practitioner agree that the cap will be kept on, but may be adjusted to one side during the visit. This approach provides an opportunity for self-control and a condition for cooperation. William gets to choose something from the gift box, and his mother tells him that he will get 30 minutes of screen time as a reward when they get home.

Future visits

From now on, William will always have the appointments in the morning. New steps are added to the visual support as William's progress and endurance continues to increase. The principles of responsibility and control are used consistently.

Diagnosis: Neurodevelopmental disorder (Autism and ADD)

Communication: She is untalkative and quiet.

Treatment: personalised acclimatisation to the dental care environment

Background: Nelly has been a patient at the clinic for many years and it has worked well. Nelly is now in her teens and does not want to be involved at all when it comes to her personal hygiene. She refuses to take care of her oral health at home and no longer wants to come to the clinic.

Preparations: The practitioner calls Nelly's mother for a preliminary consultation. The mother says that Nelly is very introverted, anxious and has considerable problems with both school and her peers. Because of this, she now has a companion dog called Alice who has made the situation better. Alice will from now on accompany her to the dental clinic*. It is decided that as a reward after each visit, Nelly gets to choose a small gift.

Personalised acclimatisation to the dental care environment plan: Nelly and Alice first arrive at the clinic for a reassuring "meet and greet" visit where she will have an opportunity to introduce her dog. Shortly afterwards, further structured visits are booked with a visual support that shows the sequence of events.

* Procedures for companion dogs can be compared to how the clinic handles, for example, a guide dog accompanying a person with a visual impairment. It is important to remember to book the last time slot of the day and additional cleaning after the visit.

Visit 1

Nelly arrives at the clinic with her mother, excited to show off her dog Alice. Together they walk towards the treatment room. Nelly hesitates, but Alice is curious and pulls Nelly into the treatment room. They look around and Nelly sits on the edge of the treatment chair. The practitioner interprets this as a sign that Nelly is ready to participate in a simpler inspection. Nelly becomes scared and sad when the chair is reclined. She no longer wants to stay and goes home.

Evaluation: How could the practitioner have acted differently by using a low arousal approach? The practitioner should not have deviated from the planned schedule (to introduce the dog and to look around). Trust was broken and it can take time and be difficult to rebuild. By deviating from the planned schedule, the practitioner has breached the principle of responsibility.

After the evaluation, the mother is contacted to talk about her and Nelly's experience, what happened and how Nelly reacted afterwards. It is decided in consultation with the mother to schedule another visit as soon as possible.

Visit 2

Nelly and Alice come to the clinic for another reassuring visit. Nelly has been given a simple visual support beforehand that clearly illustrates today's schedule. The visit includes visiting and presenting her dog Alice.

Nelly introduces Alice to the practitioner and together they enter the treatment room. The practitioner and Nelly play with Alice. After a while, Nelly becomes relaxed and looks around the room. The practitioner and Nelly agree that Nelly will try to sit in the treatment chair and get her teeth examined with a mirror at the next visit (she gets to take a mouth mirror with her at home). At the end of the visit, Nelly gets to choose a small gift.

Thoughts after the visit: The practitioner used the principle of responsibility by offering a new, reassuring visit and by following the visual support sequence carefully. Nelly felt safe and was able to maintain her self-control. Trust and the conditions for successful visits have now been established, and with regained confidence.

Visit 3

Nelly has been looking at today's visual support and practicing how to mirror her teeth at home. Nelly is a little hesitant to sit in the treatment chair, but when it is suggested that Alice can sit on her lap, she says "OK". Nelly first gets to examine Alice's teeth with her mirror. Nelly then cooperates when it is time for her own teeth to be inspected with a mirror.

Confidence is restored and the practitioner can suggest minor adjustments (such as letting her dog Alice sit on her lap).

Future visits

Repeated in the same way, adding small elements gradually. Nelly's endurance during treatment increases after each visit. The principles of responsibility and control are used consistently.

Gunilla klingberg specialist dentist in paediatric

Everyone who works with children should be well acquainted with the United Nations Convention on the Rights of the Child (Convention on the Rights of the Child, CRC). The CRC was adopted by the UN General Assembly in 1989 and from 2020 it is also incorporated into Swedish law [1]. The law is important as it clarifies that every child has needs and have rights that we must consider when meeting and treating children in healthcare including the dental setting. The rights are described in 42 different articles in the Convention, thus several articles to keep track of. One way to remember and make them visible can be to obtain and hang a poster from, for example, UNICEF or in Sweden the Ombudsman for Children [2, 3].

According to the Convention on the Rights of the Child, children are persons under 18 years of age. From the 18th birthday, the person is an adult and is no longer covered by the convention. This age limit may be different from that used in other parts of society, e.g. in Sweden comprehensive dental care is free of charge up to 19 years for adolescents or even for young adult up to and including 23 years of age. There are four articles that are particularly important in the CRC. These four principles present the CRC’s general attitude towards children and their rights and are based on the notion that children too are equal as human beings. They state that children must not be discriminated (Article 2); that the best interests of the child should be the primary consideration in all actions concerning children (Article 3); that children have the right to development and survival (Article 6); and that a child has the right to express his/her own views and that the view of the child should being given due weight in accordance with the age and maturity of the child (Article 12).

The most important of these four principles is the one about the best interests of the child. The third article states that:

"In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.

States Parties undertake to ensure the child such protection and care as is necessary for his or her well-being, taking into account the rights and duties of his or her parents, legal guardians, or other individuals legally responsible for him or her, and, to this end, shall take all appropriate legislative and administrative measures.

States Parties shall ensure that the institutions, services and facilities responsible for the care or protection of children shall conform with the standards established by competent authorities, particularly in the areas of safety, health, in the number and suitability of their staff, as well as competent supervision."

Another article (number 24) states that the child has the right to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. Of course, this includes dental care and oral health. Articles 26 and 27 are also important as they concern the importance of social security and adequate standard of living that promotes the child’s development, factors that also affect health. These articles describe children’s rights to social security and a reasonable standard of living such as housing, food and clothing and that society should provide support if the guardian lacks resources.

All meetings and treatments involving children in health care and dental care need to be adapted to the individual child. To succeed, it is important that staff who meet children have knowledge about children, about children's development and living conditions and have skills in how to communicate with children. To ensure successful appointments also from the child’s perspective we as health professionals must allow enough time for the child to manage the visit to the dental clinic. We should also ensure a child friendly environment when designing our waiting rooms and dental operatories and other treatment rooms so the child can feel safe when visiting us.

In health care and dentistry, we have an obligation to use and implement the CRC when we meet children and their families. One way can be to always have the most important articles as a posted checklist where we agree that the child has been allowed to speak, that we have really tried to involve the child in the treatment. We need to listen to the child and to her or his views and with consideration to age and maturity take the views into account in our decision making. When planning for treatment, we must ensure that the child receives care and has the right to best attainable health on the same terms as everyone else. Children must not be discriminated against and therefore not offered less or different treatment than, for example, adults. Children with disabilities must also receive the same care and attention as other children.

Medical and dental care provided within health care are evaluated at regular intervals. This can include patient surveys as well as follow-up and analyses of treatments and treatment outcomes. Here it is important to also try to find out what the child thinks about the care and treatment he or she has received. In the same way, we should ensure to include the child's perspective and needs when we plan health care environments. The Swedish Ombudsman for Children and the Swedish Association of Local Authorities and Regions offer several good examples of how this can be carried out [4, 5].

With all pieces in place, we meet the requirements for working in accordance with the principle of the best interests of the child and this in turn enables dental care to contribute to each child attaining the best possible health. Using the Convention on the Rights of the Child is both simple and obvious. In addition, it is an important way to contribute to good oral health and orofacial function for all children.

• Axel Chipumbu Havelius, ”Lågaffektivt bemötande”. Studentlitteratur AB
• Barnombudsmannen, ”Affisch om barnkonventionen på svenska”: https://www.barnombudsmannen.se/barnombudsmannen/publikationer/for-barn-och-ungdomar/affisch-om-barnkonventionen-pa-svenska/
• Barnombudsmannen, ”Uppnå kvalitet i beslut som rör unga”: https://www.barnombudsmannen.se/globalassets/dokument-for-nedladdning/publikationer/faktablad/faktablad2_uppna11.pdf
• Bo Hejlskov Elvén, ”Lågaffektivt bemötande”. Studentlitteratur AB
• Bo Hjelskov Elvéns: https://hejlskov.se
• Lag (2018:1197) om Förenta nationernas konvention om barnets rättigheter: https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-20181197-om-forenta-nationernas-konvention_sfs-2018-1197
• Mun-H-Center: https://www.mun-h-center.se (Se NPF Munvårdsprogram)
• Ross W Greene, ”Explosiva barn”. Studentlitteratur AB (Se korgmodellen mer utförligt)
• Sveriges Kommuner och Regioner, ”Barnets rättigheter”: https://skr.se/skr/demokratiledningstyrning/manskligarattigheterjamlikhet/barnetsrattigheter.106.html
• UNICEF, ”Affisch med barnkonventionen”: https://unicef.se/rapporter-och-publikationer/affisch-barnkonventionen