The Dentist-Child
Relationship:
Engaging Children’s
Cooperation Through Effective
Communication
Article in the Journal
Pediatric Dentistry
Nash, D.A.
Engaging Children’s
Cooperation in the Dental
Environment Through
Effective Communication
Pediatric Dentistry
2006;28(5):455-459.
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.
1. Tell Show Do;
2. Reflective listening;
3. Self-disclosing assertiveness; and
4. Descriptive praise.
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
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.
Tell
• TELL
– before
– during
– after
• TELL… using euphemisms
(substitute language)
• Understanding critical
• Be honest in your TELLing!
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.
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!
Haim Ginott, Ph.D
Clinical 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
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
Feelings
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.
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 . . .”
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.
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.”
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.
Dealing with Feelings
Never deny a child’s feelings:
 Outright denial: “you can’t possibly feel be scared; there
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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 . . .”
“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)
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.
Ways to Acknowledge Feelings
1. Listening quietly and attentively.
2. Acknowledging the feeling with a word: Oh …
mmm … I see.
3. Giving the feeling a name: “It sounds like you are
really nervous about coming to see me today.”
4. 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.”
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.”
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.
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.
Engaging Cooperation
Ineffective/Destructive ways to attempt to gain
cooperation—”roadblocks to communication:”
 Blaming and accusing: “If we don’t finish this silver
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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.”)
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.” )
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).
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.
I Messages
• The key to gaining cooperation by being assertive
is to understand that assertiveness is selfdisclosing.
• Self-disclosing assertive statements begin with
“I.”
• Self-disclosure improves a dentist’s personal selfawareness 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.
I Messages
1. Describe what is seen.
2. Share what is felt.
3. Describe a problem being
experienced.
4. Give information of which the
dentist is aware but of which the
child may not be aware.
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.”
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.”
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.
Engaging Cooperation
1. Describe: describe what you see, or describe
the problem. “I have trouble doing my job
when the mouth keeps closing.”
2. Give information: “When you open you mouth
really wide, I can see to put the rubber
raincoat ring on the right tooth.”
3. Say it with a word: “The hands!”
4. Talk about YOUR feelings: “I am really
frustrated because I can’t spray sleepy water
on teeth I can’t see.”
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.”
Praise
When wanting to reinforce positive behavior,
instead of evaluating…Describe.
1. Describe what you see. “I see a young man
who is holding his mouth open really wide
and sitting really still!”
2. Describe what you feel. “It is really a
pleasure to be the dentist of a young lady
who opens her mouth so wide.”
3. 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.”
Praise
In summary:
1. DO NOT use global terms of evaluation. Avoid great,
good, wonderful, as in “you’re being good.”…and
certainly negative and pejorative judgments such as
“you’re being bad.”
2. 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.”
3. ALLOW the child to form their own evaluations of
their behavior.
4. ALWAYS look for opportunities to acknowledge
correctness.
Additional Ginott Principles
 Children are Equal in Dignity
With 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?”
Gordon Model for
Communicating with Children
Parent Effectiveness Training
by Thomas Gordon
Roadblocks to Communication
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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
“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.
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.
“Owning the Problem”
Area of Acceptable
Behavior for Dentist:
• Child Owns the Problem
• No Problem
Area of Unacceptable
Behavior for Dentist:
• Dentist Owns the
Problem
Active Listening...
is used when:
the child “owns the problem.”
WHEN THE CHILD
“OWNS THE PROBLEM”
TIRED
Child
ENCODING
PROCESS
DECODING
PROCESS
“When are you going
to be finished?“
CHILD
TIRED
Dentist
WHEN THE CHILD
“OWNS THE PROBLEM”
TIRED
Child
ENCODING
PROCESS
CHILD
School
DECODING
PROCESS
“When are you going
to be finished?”
Dentist
“You want to get back to school.”
“No, I didn’t mean that. I meant I am
really tired of holding my mouth open..”
WHEN THE CHILD
“OWNS THE PROBLEM”
TIRED
Child
ENCODING
PROCESS
DECODING
PROCESS
“When are you
going to be finished?”
“You’re getting
tired.”
CHILD
TIRED
Dentist
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.
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.
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.”
When the Dentist
“Owns the Problem”
Frustrated
Dentist
ENCODING
PROCESS
“I cannot put the rubber raincoat on
with hands over the mouth.!”
When the Dentist
“Owns the Problem”
Frustrated
Dentist
ENCODING
PROCESS
“You sure are
no help!”
DECODING
PROCESS
I
Am Bad
Child
“You Messages”
 Are put-downs.
 Impugn the child’s character.
 Deprecate the child as a person.
 Shatter the child’s sense of self; selfesteem.
 Underline the child’s inadequacies.
 Cast a judgment on the child’s
personality
 They point the finger of blame toward
the child, and are roadblocks to
communication.
“You Messages”
Are Not Helpful
Our natural tendency in times when the child is
not behaving in a manner acceptable to us is to
send a “You Message”:
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YOU stop that!
YOU must not do that!
Don’t YOU ever…!
YOU are being bad!
YOU are not acting like a big girl!
Why can’t YOU be good?!
YOU should know better.
When The Dentist
“Owns the Problem”
Frustrated
Dentist
ENCODING
PROCESS
DECODING
PROCESS
“I cannot put the
rubber raincoat on
with hands over the
mouth.”
He is
Frustrated
Child
“I Messages”
 “I Messages” are more effective in
influencing a child to modify behavior.
 “I Messages” much less apt to provoke
resistance and rebellion.
 “I Messages” are less threatening to the
child.
 “I Messages” are more effective because
they place responsibility for change
within the child.
“I Messages”
“ I Messages” can be sent non-verbally
as well:
A stern look says, “I am unhappy with you
behavior.”
A firm positioning of a squirming child in
the chair says, “I need to work on a non-
moving target.”
Voice Intonation
(Voice Control)
 Occasionally it is necessary to send a strong “I
Message” for a child who is being particularly
uncooperative, and specifically when there is a
dimension of defiance in the child’s behavior.
 Three elements of effective use of the “voice
control” with difficult child: 1) voice must be
raised to higher level than normal; 2) voice must
reflect sternness; 3) and child must be looking
directly into practitioner’s face.
Summary
 When you have a problem with the child’s
behavior…Send An “I Message!”
 When the child is having a
problem…”Active Listen!”
 When neither of you have a problem,
continually reinforce the child’s behavior,
citing tangible aspects of that behavior
through “Descriptive Praise!”
Dentists are Professionals
 In caring for children, “Dentists are
professionals—engaging children therapeutically.
 The care provided for improving the child’s oral
health must be effective, that is, therapeutic.
 In providing care, the dentist’s communication
must also be therapeutic, that is, communication
that will result in cooperation being gained and
maintained, as well as the child being treated
humanely and affirmed.