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The parents and the dentist
The parents and the dentist
Esther Schour,'* At.S.S., Chicago
The relationship of a dentist to his child patient cannot be considered exclusive of the child’s parents. The dentist may find himself part of a psychological inter relationship on the understanding of which may depend the effectiveness of his treatment.
For optimal effectiveness of dental treat ment of children, parents and the dentist have work to do together. Our task is to understand the nature of this working re lationship and to find means of making it most constructive. The relationship of a dentist to his child patient cannot be con sidered exclusive of the child’s parents. It is hard for parents to be comfortable and confident today. Feelings of anxiety,
self-reproach, and a sense of defeat are widespread among them. Many factors contribute to this. First of all, there is a ferment in the world in which we live which arouses anxiety in all of us. Then too, our own democratic culture which prizes individual uniqueness gives opportunity for individual expression and creativity, but does not provide modern parents with the security offered by older, more authoritarian cultures in which be havior is culturally prescribed. Our stand ards and values are in flux. The quick changes in the pattern of family life, with the confusion and shifts in recommended child-rearing practices in the past 35 years have left parents confused as to their role and goals. The health-consciousness of our time has also placed a heavy burden on par
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ents. They feel responsible for safeguard ing their children’s health; they need to know what is normal and when to look for professional advice for medical prob lems, dental problems, and emotional problems in their children. In increasing numbers they have participated in differ ent kinds of parent education programs, and they have learned a great deal about themselves and their children. While we believe that knowledge, like truth, can make men free, it is apparent that new knowledge which upsets traditional be liefs has added to parents’ anxiety. Moreover, there is a tendency in our society and on the part of professional people dealing with children to blame parents, particularly mother, for all the problems of their children, including their dental problems. It is as though we re garded parents as an affliction from which children suffer. This attitude was not always so. Until about 60 years ago a child’s problems were attributed to hered ity and constitution. A child was bom good or bad. Parents were fortunate to have good children; they were objects of pity if their child was bad. This explana tion of the cause of the child’s maladjust ment was relatively easy for parents. Then about 35 years ago there was a swing to the other extreme. Environment came to be regarded as the most powerful force in shaping personality. Since parents are the child’s earliest environment, they were held responsible for the kind of child they brought up. Actually, the factors respon sible for children’s maladjustment are multiple and interwoven. Both constitu tion and environment play their roles. It is not only an oversimplification but ac tually not true that parents are totally responsible for all their children’s prob lems. To blame parents is futile. Practically all parents consciously aspire to be good parents. They want their children to be secure, happy, healthy and capable of achievement. They want to be successful in rearing them. What often interferes
with this are the parents’ own personality problems. The dentist’s task in dealing with par ents is twofold: (1) to involve the parent in facilitating the child’s dental treatment; (2) to educate the parents to the im portance of early treatment and preven tion of dental disease. Just as knowledge of the biology and structure of the dental tissues enriches dental technics and den tal skill, so more explicit knowledge of the psychological elements in the rela tionship between the parents and the dentist may enhance the dentist’s under standing and use of this interpersonal relationship. H O W P A R E N T S SEE T H E D E N T IS T
Parents’ attitudes toward the dentist vary. For the most part, they are respectful toward him, dependent on his knowledge and skill, eager to make a good impression on him and to extend themselves in meet ing his recommendations. Because par ents (and it is usually mothers) who bring the children to the dentist are apt to be under stress, they may be particularly sensitive and responsive to the dentist’s behavior toward them and their offspring. Many parents are themselves afraid of the dentist; their own fears, their low tolerance of pain and discomfort, are likely to color their attitude toward the dentist and to enhance the anxiety they feel about their (Child’s dental care. Nevertheless, when they are reassured and the dentist demonstrates kindliness and competence in working with the child, they are likely to develop positive feelings for him and trust in him. They may see the dentist realistically as the expert who may hurt before he helps. It is common experience that even parents who are afraid of the dentist, like and admire him as they come to know him, and show less fear of dental treatment for themselves and their child. All parents expect the dentist to be in terested in their child. They want the
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dentist to care, to be gentle, to be sympa thetic about the child’s pain and fears. Parents who are most insecure and fearful are most likely to convey these feelings toward their children and both parent and child are especially needful of the dentist’s warmth, reassurance and pa tience. If the dentist can offer this, he can mitigate the fears of both parent and child and win their confidence, and teach the parent what he or she needs to know to do his part in the management of the child’ s dental condition. This is why the personality of the dentist and his ways of working with parents are extremely important for the kind of collaborative relations he can work out with them. Because the dentist, especially if he is an older person, is apt to be seen as an expert— a figure of authority— parents may bring to their relationship with him feelings, fears, and expectations which they developed first in connection with their own parents and through their cu mulative experiences with other persons in authority. If their feelings were pre dominantly positive, the possibilities are favorable for parent and dentist to work together smoothly for the child’s dental welfare. But unsolved conflicts from childhood persist in most of us, and these may make it difficult for the parent to see the dentist objectively. A parent may have unrealistic fears of the dentist and unreasonable feelings of anger, resent ment and defiance toward the dentist as an authority figure. A parent’s expec tations for praise and approval may be inordinate. He may feel that the den tist blames him, is not sympathetic to his efforts, is too dominating, makes unrea sonable demands, does not understand him or is too rough on the child. Many parents feel inadequate and ashamed of their child’s dental problems or misbe havior with the dentist from whom they seek approval. Such unrealistic attitudes make the dentist’s task more difficult, but even unrealistic attitudes can and do often yield when the dentist can convey an
attitude that parents are people too, when -he can accept their strengths, weaknesses and angry outbursts and when he demonstrates appreciation and support— rather than blame—of the par ents’ own problems. There are extremely disturbed parents who cannot be involved even minimally with the dentist’s best knowledge and skill. The dentist’s task in these situations may be to minimize a parent’s interference and focus on the treatment and education of the child pa tient. H O W T H E D E N T IS T S E E S P A R E N T S
The dentist brings into his relationship with parents a concept of himself as an expert. From this he derives a feeling of professional responsibility, competence, authority and prestige. He expects par ents to respect his expertness and to ac cept and meet his prescriptions. As den tistry moves forward in its preventive and social functions, it is necessary that in addition to being a healer, the dentist see himself as an educator. How he feels and acts toward parents and how he uses his position of authority with parents are in part determined by his own early experiences and relation ships with his own parents. Several studies give some insight into the den tist’s personality as this relates to his choice of dentistry as a career. Four inde pendent studies14 on the personality characteristics of dental students sought to infer from their findings a general pat tern of attitudes that would be descriptive of the majority of individuals choosing dentistry as their profession. The “typi cal” dentist who emerges from these stud ies might be described as follows: (1) The need for autonomy is frequently an important motivation in his choice of dentistry as a profession; (2) his early experiences often indicate the influence of a repressive authoritative parent toward whom he could not as a child ex press his aggression directly; (3) this
S C H O U R . .. V O L U M E 6?, A UG UST 1964 • 167/249
produces throughout his life a difficulty in relating to authority figures; (4) there may be a need to express aggression to authority figures indirectly; (5) his other characteristics include methodicalness, some rigidity and inflexibility, neatness and orderliness. To the extent that these studies of the dentist’s personality are valid, the dentist who specializes in treat ment of children, and therefore must work with parents who present many different kinds of behavior, is faced with a great challenge— he must understand and try to keep under control his own difficulties with authority which stem from his childhood experiences, which may be triggered by a particular kind of parental behavior to which he is vul nerable, and this reaction may hamper his ability to deal with some parents on a mature level. But again, the dentist, like the parent, is influenced not only by his early expe riences. Subsequent experiences and his current life situation, both at home and in the office, may alter his reaction to parents. A light touch (figuratively speak ing) and a little benign humor can go a long way with tense parents. Most of the dentists with whom I spoke recognized that the personality of the dentist is a decisive factor not only in the way in which he deals with prob lems, but in the kinds of problems he en counters with parents. One very wise orthodontist spoke of some of his younger colleagues as being not “ accident-prone” but “parent-prone.” Out of a dozen case histories which pedodontists and orthodontists generously gave me, I have summarized two for presentation of parent-dentist interaction. A very overanxious young mother brought her seven-year-old son for his first dental visit. Before the visit she took pains to instruct him that the dentist would not hurt him. In the office she answered all questions addressed to him, and repeated all instructions given by the dentist. She hovered over the child and
the dentist in such a way as to prevent the dentist from achieving initial rapport with the boy. Afterwards she cuddled the boy and comforted him with such ques tions as: “ Were you hurt? That wasn’t so bad, was it?” and to the dentist— “ I hope you won’t have to do this often.” The pedodontist was irritated by mother. He criticized her for her errors in ap proach and for infantilizing her son. Nevertheless, he had in mind the goal of establishing rapport with the boy for continued treatment and he recognized the boy’s fearfulness, so he let mother remain in the operating room. Although he resented her overprotection, he was not himself made so anxious by her presence that he had to ask her to leave. His irritation with mother seemed to be rather well warranted in view of her handling of the child. There are no stereotyped rules about whether one allows or does not allow a mother in the operating room. It depends on the age of the child, the degree of the child’s anxiety, the capacity of the mother to give security, and on the dentist’s own personal feelings. A preschool child most often needs mother’s presence in the operating room for security. A sevenyear-old child may still need his mother, especially in his first encounter with the dentist. If the child needs the parent, it is reasonable that the parent should be allowed to remain. But if a mother’s anxiety is so great that she cannot give the child support or that she adds to his fears, then the dentist may have to ask her to go into the waiting room, for her own comfort as well as the child’s. He may also ask a parent to leave in order to allay his own discomfort at being observed by a parent, regardless of whether the parent is overanxious or composed. When a dentist establishes a rule that no parents are permitted in the operating room, he should be clear as to the basis for this. It helps a parent to know that she is being excluded not be cause she is a problem but because the
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dentist can work more effectively with the child without her. In another situation a father brought to the orthodontist his submissive, pleas ant ten-year-old daughter. He was a wealthy, overbearing man, with attitudes that money can buy anything. The child’s problem was thumbsucking which has many psychological determinants. Em phatically and arrogantly father told the dentist he had brought her because he wanted the dentist to make “one of those wire things that stops thumbsucking.” He wanted it constructed immediately and put in her mouth; he was sick and tired of seeing her suck her thumb; the only reason she did it, he said, was to irritate him. The dentist tried unsuccessfully, in the child’s presence to discuss the “habit” in such a way that father might gain some insight into his daughter’s prob lems. Angry at the father’s failure to accept his explanation, the dentist asked the father to step out and talked with the girl alone. He asked her if her father was always this way, and she said yes. He asked her if she could stop sucking her thumb, and she said yes. He asked her if she wanted him to make the ap pliance, and she said she did not care. The dentist did make the appliance. Two weeks later father returned with his daughter, said the appliance did not work, and asked its removal. The dentist removed the appliance, then talked with the girl alone, telling her that he knew she sucked her thumb merely to irritate her father; that he did not blame her for this—he felt father deserved it— but that she was hurting herself by deforming her occlusion. He appealed to her to stop. Two weeks later she called him to tell him she had stopped sucking her thumb. It would appear that the dentist achieved a successful result. Yet in look ing at the dentist’s attitudes and behavior in this case it is clear that his professional judgment was handicapped by strong per
sonal feelings. He was very hostile to father, and talked with the child against her father. He resented father’s harshness and domination of the child, and father’s arrogance and disrespect of his own ex pertness. He knew on the basis of his professional knowledge and experience that the wire appliance was not indicated —in this case it was a punitive and not a dental therapeutic measure. But he was unable to stand up directly to father and refuse his demand; instead he was drawn into doing the father’s bidding against his professional judgment. This father appears to have rearoused the dentist’s own childhood struggle with authority. It is a striking example of how the forces of the past may inappropriately regulate the behavior of the present. If the dentist could have seen this situation more objectively he might still realistically feel angry and critical of fa ther for his punitiveness to his daughter and his disrespect of professional advice, but it might have been possible for him to have some acceptance of the father’s anxiety and irritability about the prob lem; he might have understood and ac knowledged the father’s wish to cure it; he would have talked to the father not in the presence of the child, explain ing that thumbsucking in a ten year old is a symptom of conflict and immaturity, that an appliance is not a cure, and he could have .talked to the child about thumbsucking which both dentist and child believed she could control. (I am not suggesting that all thumbsucking can be consciously controlled.) G E N E R A L A T T IT U D E S A N D C O N T R O L S
There are no easy answers to dealing with parents, but there are some general atti tudes and goals which might be kept in mind: 1. The dentist must recognize that parents differ and that all cannot be treated the same way; each parent must be regarded as an individual. The dentist
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has an opportunity to learn about a parent and his relationship to his child through talking with the parent, through talking with the child, and through ob serving their behavior and attitudes toward each other. He needs knowledge and understanding of parents and parentchild relationships so he can deal with parents differentially in relation to secur ing their cooperation in meeting the child’s dental health needs. 2. The dentist must respect the par ent’s role in the child’s dental treatment. Parents should be given an explanation of the ground rules. The dentist needs to talk with the parents alone to make clear to the parent his responsibilities. For in stance, it is necessary that a young child be brought to the office; that the older child be encouraged to keep appoint ments; that active help be given to a young child in home management pro cedures— brushing the teeth, reducing sweets, wearing appliances—because the young child cannot carry this responsi bility alone. But, by the same token, the dentist needs to understand that parents usually cannot carry the responsibility for home management of the adolescent’s dental problems because of the ado lescent’s normal thrust for independence. And the dentist needs to understand that parents may be ineffective in home man agement of even young children if the relationship between the parent and the child is already too conflictive. In these instances, as with the adolescent, the dentist must work directly with the child to win his cooperation. Parents should be kept informed of the child’s progress and response to treat ment—but not with an attitude that it is the parent’s fault that there are diffi culties. 3. It is important for the dentist to know when to be flexible about ground rules and other recommendations. A rela tively mature mother with a good rela tionship with her child may be able to meet the dentist’s recommendation that
there be no in-between-meal sweets. The overindulgent mother may find it ex tremely difficult to deny the child’s grati fication or to set limits, and she may be unable to resist the child’s wheedling. When the dentist understands this, he may be more flexible. He may suggest to mother that, if the child must have sweets, he should brush his teeth or that he may have all his sweets at one time and then brush his teeth. The dentist needs to show some flexibility too in rearranging an ap pointment, not as a regular practice, but as a special favor under special circum stances. 4. The dentist needs to realize that dental education of parents, like all edu cation, is a continuing process. With most parents it is not accomplished in a single session or in an occasional interview. It requires the dentist’s sustained, persistent efforts. A lapse on the part of the parent in following recommendations does not necessarily mean she is uncooperative. There are lapses in all learning. 5. It is essential that the dentist have some understanding of himself and of his role with parents. He needs some selfawareness in order to be freer to act— to do what is professionally sound and ap propriate as a dentist. He needs to under stand his meaning to parents; to be aware of his own characteristic ways of meeting the demands of parents; and to keep his focus on helping parents meet the dental health needs of their child. He needs to be clear in his own mind that his involve ment with parents is not for the purpose of exploring or treating the parents’ psy chological problems. In this connection I want to mention a case reported in the dental literature. It involved a 13-yearold adolescent girl with rampant decay and oral signs of nutritional deficiency. The dentist recognized that emotions and environment might be affecting her den tal health. Having observed the child and noted the mother’s cold and unsympa thetic face, which to him suggested cruelty, the dentist asked the mother
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bluntly, “ Why do you hate that child?” of children and their parents through such While the dentist in this particular case suggestions. surrounded the question with many Finally, dentistry, parallel with other cushions and offered to refer the mother health professions, is increasingly con for help, I submit it is not within the cerned not only with the diagnosis and dentist’s competence and responsibility to treatment of dental disease but with den explore attitudes or make interpretations tal health education and prevention. To enable dentists to be more effective in in this way. 6. The dentist is in a strategic posi their work with parents toward these tion to make referral of parents to appro ends, dentistry will need to give greater priate sources. It is very common for attention to the learning and teaching parents who have a good relationship of the psychology of interpersonal rela with the dentist to discuss with him their tionships by including programs of this child’s problems, and their own marital nature in the curricula of dental schools. 664 North Michigan Avenue and personal problems. It is important that the dentist not become involved in the personal life of the parent or interfere Presented before the M id-W inter meeting, C hicago in the parent’s interpersonal relationship Dental Society, February 5, 1964. *Administrative director, Child Therapy Program, In with his child. He can be an interested stitute for Psychoanalysis, Chicago; consultant, social service department, Veterans Administration, Hines listener but he is not trained to treat Hospital. !. Heist, P. Personality characteristics of dental stu the parent-child relationship or the dents. Educational Record 41:240 July I960. child’s emotional disturbance. Depending 2. More, D. M., and Kohn, N. Some motives for on the degree to which he is psychologi entering dentistry. Am. J. Soc. 66:48, I960. 3. Nachmann, Barbara. Childhood experience and cally attuned, the dentist may suggest vocational choice in law, dentistry, and social work. J. Counsel. Psychol. 7:243, I960. that parents seek help from competent 4. Kirk, Barbara A.; Cummings, Roger W., and Herbert R. Personal and vocational character sources. Many dentists have made a last Hackett, istics of dental students. Personnel & Guidance Journal, ing contribution to the emotional welfare Feb. 1963, p. 522.
Personal Responsibility • Self-indulgence— the principle o f pleasure before duty— is practiced across the length and breadth o f the land. It is undermining those attributes o f personal respon sibility and self-discipline which are essential to our national survival. It is creating citizens w ho reach maturity with a warped sense o f values and an undeveloped conscience. / . Edgar H oover. Chicago Sun-Tim es, O ctob er 10, 1962, p. 4.
Esther Schour,'* At.S.S., Chicago
The relationship of a dentist to his child patient cannot be considered exclusive of the child’s parents. The dentist may find himself part of a psychological inter relationship on the understanding of which may depend the effectiveness of his treatment.
For optimal effectiveness of dental treat ment of children, parents and the dentist have work to do together. Our task is to understand the nature of this working re lationship and to find means of making it most constructive. The relationship of a dentist to his child patient cannot be con sidered exclusive of the child’s parents. It is hard for parents to be comfortable and confident today. Feelings of anxiety,
self-reproach, and a sense of defeat are widespread among them. Many factors contribute to this. First of all, there is a ferment in the world in which we live which arouses anxiety in all of us. Then too, our own democratic culture which prizes individual uniqueness gives opportunity for individual expression and creativity, but does not provide modern parents with the security offered by older, more authoritarian cultures in which be havior is culturally prescribed. Our stand ards and values are in flux. The quick changes in the pattern of family life, with the confusion and shifts in recommended child-rearing practices in the past 35 years have left parents confused as to their role and goals. The health-consciousness of our time has also placed a heavy burden on par
SC H O U R . . . V O LU M E 69, A UG UST 1964 • 167/247
ents. They feel responsible for safeguard ing their children’s health; they need to know what is normal and when to look for professional advice for medical prob lems, dental problems, and emotional problems in their children. In increasing numbers they have participated in differ ent kinds of parent education programs, and they have learned a great deal about themselves and their children. While we believe that knowledge, like truth, can make men free, it is apparent that new knowledge which upsets traditional be liefs has added to parents’ anxiety. Moreover, there is a tendency in our society and on the part of professional people dealing with children to blame parents, particularly mother, for all the problems of their children, including their dental problems. It is as though we re garded parents as an affliction from which children suffer. This attitude was not always so. Until about 60 years ago a child’s problems were attributed to hered ity and constitution. A child was bom good or bad. Parents were fortunate to have good children; they were objects of pity if their child was bad. This explana tion of the cause of the child’s maladjust ment was relatively easy for parents. Then about 35 years ago there was a swing to the other extreme. Environment came to be regarded as the most powerful force in shaping personality. Since parents are the child’s earliest environment, they were held responsible for the kind of child they brought up. Actually, the factors respon sible for children’s maladjustment are multiple and interwoven. Both constitu tion and environment play their roles. It is not only an oversimplification but ac tually not true that parents are totally responsible for all their children’s prob lems. To blame parents is futile. Practically all parents consciously aspire to be good parents. They want their children to be secure, happy, healthy and capable of achievement. They want to be successful in rearing them. What often interferes
with this are the parents’ own personality problems. The dentist’s task in dealing with par ents is twofold: (1) to involve the parent in facilitating the child’s dental treatment; (2) to educate the parents to the im portance of early treatment and preven tion of dental disease. Just as knowledge of the biology and structure of the dental tissues enriches dental technics and den tal skill, so more explicit knowledge of the psychological elements in the rela tionship between the parents and the dentist may enhance the dentist’s under standing and use of this interpersonal relationship. H O W P A R E N T S SEE T H E D E N T IS T
Parents’ attitudes toward the dentist vary. For the most part, they are respectful toward him, dependent on his knowledge and skill, eager to make a good impression on him and to extend themselves in meet ing his recommendations. Because par ents (and it is usually mothers) who bring the children to the dentist are apt to be under stress, they may be particularly sensitive and responsive to the dentist’s behavior toward them and their offspring. Many parents are themselves afraid of the dentist; their own fears, their low tolerance of pain and discomfort, are likely to color their attitude toward the dentist and to enhance the anxiety they feel about their (Child’s dental care. Nevertheless, when they are reassured and the dentist demonstrates kindliness and competence in working with the child, they are likely to develop positive feelings for him and trust in him. They may see the dentist realistically as the expert who may hurt before he helps. It is common experience that even parents who are afraid of the dentist, like and admire him as they come to know him, and show less fear of dental treatment for themselves and their child. All parents expect the dentist to be in terested in their child. They want the
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dentist to care, to be gentle, to be sympa thetic about the child’s pain and fears. Parents who are most insecure and fearful are most likely to convey these feelings toward their children and both parent and child are especially needful of the dentist’s warmth, reassurance and pa tience. If the dentist can offer this, he can mitigate the fears of both parent and child and win their confidence, and teach the parent what he or she needs to know to do his part in the management of the child’ s dental condition. This is why the personality of the dentist and his ways of working with parents are extremely important for the kind of collaborative relations he can work out with them. Because the dentist, especially if he is an older person, is apt to be seen as an expert— a figure of authority— parents may bring to their relationship with him feelings, fears, and expectations which they developed first in connection with their own parents and through their cu mulative experiences with other persons in authority. If their feelings were pre dominantly positive, the possibilities are favorable for parent and dentist to work together smoothly for the child’s dental welfare. But unsolved conflicts from childhood persist in most of us, and these may make it difficult for the parent to see the dentist objectively. A parent may have unrealistic fears of the dentist and unreasonable feelings of anger, resent ment and defiance toward the dentist as an authority figure. A parent’s expec tations for praise and approval may be inordinate. He may feel that the den tist blames him, is not sympathetic to his efforts, is too dominating, makes unrea sonable demands, does not understand him or is too rough on the child. Many parents feel inadequate and ashamed of their child’s dental problems or misbe havior with the dentist from whom they seek approval. Such unrealistic attitudes make the dentist’s task more difficult, but even unrealistic attitudes can and do often yield when the dentist can convey an
attitude that parents are people too, when -he can accept their strengths, weaknesses and angry outbursts and when he demonstrates appreciation and support— rather than blame—of the par ents’ own problems. There are extremely disturbed parents who cannot be involved even minimally with the dentist’s best knowledge and skill. The dentist’s task in these situations may be to minimize a parent’s interference and focus on the treatment and education of the child pa tient. H O W T H E D E N T IS T S E E S P A R E N T S
The dentist brings into his relationship with parents a concept of himself as an expert. From this he derives a feeling of professional responsibility, competence, authority and prestige. He expects par ents to respect his expertness and to ac cept and meet his prescriptions. As den tistry moves forward in its preventive and social functions, it is necessary that in addition to being a healer, the dentist see himself as an educator. How he feels and acts toward parents and how he uses his position of authority with parents are in part determined by his own early experiences and relation ships with his own parents. Several studies give some insight into the den tist’s personality as this relates to his choice of dentistry as a career. Four inde pendent studies14 on the personality characteristics of dental students sought to infer from their findings a general pat tern of attitudes that would be descriptive of the majority of individuals choosing dentistry as their profession. The “typi cal” dentist who emerges from these stud ies might be described as follows: (1) The need for autonomy is frequently an important motivation in his choice of dentistry as a profession; (2) his early experiences often indicate the influence of a repressive authoritative parent toward whom he could not as a child ex press his aggression directly; (3) this
S C H O U R . .. V O L U M E 6?, A UG UST 1964 • 167/249
produces throughout his life a difficulty in relating to authority figures; (4) there may be a need to express aggression to authority figures indirectly; (5) his other characteristics include methodicalness, some rigidity and inflexibility, neatness and orderliness. To the extent that these studies of the dentist’s personality are valid, the dentist who specializes in treat ment of children, and therefore must work with parents who present many different kinds of behavior, is faced with a great challenge— he must understand and try to keep under control his own difficulties with authority which stem from his childhood experiences, which may be triggered by a particular kind of parental behavior to which he is vul nerable, and this reaction may hamper his ability to deal with some parents on a mature level. But again, the dentist, like the parent, is influenced not only by his early expe riences. Subsequent experiences and his current life situation, both at home and in the office, may alter his reaction to parents. A light touch (figuratively speak ing) and a little benign humor can go a long way with tense parents. Most of the dentists with whom I spoke recognized that the personality of the dentist is a decisive factor not only in the way in which he deals with prob lems, but in the kinds of problems he en counters with parents. One very wise orthodontist spoke of some of his younger colleagues as being not “ accident-prone” but “parent-prone.” Out of a dozen case histories which pedodontists and orthodontists generously gave me, I have summarized two for presentation of parent-dentist interaction. A very overanxious young mother brought her seven-year-old son for his first dental visit. Before the visit she took pains to instruct him that the dentist would not hurt him. In the office she answered all questions addressed to him, and repeated all instructions given by the dentist. She hovered over the child and
the dentist in such a way as to prevent the dentist from achieving initial rapport with the boy. Afterwards she cuddled the boy and comforted him with such ques tions as: “ Were you hurt? That wasn’t so bad, was it?” and to the dentist— “ I hope you won’t have to do this often.” The pedodontist was irritated by mother. He criticized her for her errors in ap proach and for infantilizing her son. Nevertheless, he had in mind the goal of establishing rapport with the boy for continued treatment and he recognized the boy’s fearfulness, so he let mother remain in the operating room. Although he resented her overprotection, he was not himself made so anxious by her presence that he had to ask her to leave. His irritation with mother seemed to be rather well warranted in view of her handling of the child. There are no stereotyped rules about whether one allows or does not allow a mother in the operating room. It depends on the age of the child, the degree of the child’s anxiety, the capacity of the mother to give security, and on the dentist’s own personal feelings. A preschool child most often needs mother’s presence in the operating room for security. A sevenyear-old child may still need his mother, especially in his first encounter with the dentist. If the child needs the parent, it is reasonable that the parent should be allowed to remain. But if a mother’s anxiety is so great that she cannot give the child support or that she adds to his fears, then the dentist may have to ask her to go into the waiting room, for her own comfort as well as the child’s. He may also ask a parent to leave in order to allay his own discomfort at being observed by a parent, regardless of whether the parent is overanxious or composed. When a dentist establishes a rule that no parents are permitted in the operating room, he should be clear as to the basis for this. It helps a parent to know that she is being excluded not be cause she is a problem but because the
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dentist can work more effectively with the child without her. In another situation a father brought to the orthodontist his submissive, pleas ant ten-year-old daughter. He was a wealthy, overbearing man, with attitudes that money can buy anything. The child’s problem was thumbsucking which has many psychological determinants. Em phatically and arrogantly father told the dentist he had brought her because he wanted the dentist to make “one of those wire things that stops thumbsucking.” He wanted it constructed immediately and put in her mouth; he was sick and tired of seeing her suck her thumb; the only reason she did it, he said, was to irritate him. The dentist tried unsuccessfully, in the child’s presence to discuss the “habit” in such a way that father might gain some insight into his daughter’s prob lems. Angry at the father’s failure to accept his explanation, the dentist asked the father to step out and talked with the girl alone. He asked her if her father was always this way, and she said yes. He asked her if she could stop sucking her thumb, and she said yes. He asked her if she wanted him to make the ap pliance, and she said she did not care. The dentist did make the appliance. Two weeks later father returned with his daughter, said the appliance did not work, and asked its removal. The dentist removed the appliance, then talked with the girl alone, telling her that he knew she sucked her thumb merely to irritate her father; that he did not blame her for this—he felt father deserved it— but that she was hurting herself by deforming her occlusion. He appealed to her to stop. Two weeks later she called him to tell him she had stopped sucking her thumb. It would appear that the dentist achieved a successful result. Yet in look ing at the dentist’s attitudes and behavior in this case it is clear that his professional judgment was handicapped by strong per
sonal feelings. He was very hostile to father, and talked with the child against her father. He resented father’s harshness and domination of the child, and father’s arrogance and disrespect of his own ex pertness. He knew on the basis of his professional knowledge and experience that the wire appliance was not indicated —in this case it was a punitive and not a dental therapeutic measure. But he was unable to stand up directly to father and refuse his demand; instead he was drawn into doing the father’s bidding against his professional judgment. This father appears to have rearoused the dentist’s own childhood struggle with authority. It is a striking example of how the forces of the past may inappropriately regulate the behavior of the present. If the dentist could have seen this situation more objectively he might still realistically feel angry and critical of fa ther for his punitiveness to his daughter and his disrespect of professional advice, but it might have been possible for him to have some acceptance of the father’s anxiety and irritability about the prob lem; he might have understood and ac knowledged the father’s wish to cure it; he would have talked to the father not in the presence of the child, explain ing that thumbsucking in a ten year old is a symptom of conflict and immaturity, that an appliance is not a cure, and he could have .talked to the child about thumbsucking which both dentist and child believed she could control. (I am not suggesting that all thumbsucking can be consciously controlled.) G E N E R A L A T T IT U D E S A N D C O N T R O L S
There are no easy answers to dealing with parents, but there are some general atti tudes and goals which might be kept in mind: 1. The dentist must recognize that parents differ and that all cannot be treated the same way; each parent must be regarded as an individual. The dentist
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has an opportunity to learn about a parent and his relationship to his child through talking with the parent, through talking with the child, and through ob serving their behavior and attitudes toward each other. He needs knowledge and understanding of parents and parentchild relationships so he can deal with parents differentially in relation to secur ing their cooperation in meeting the child’s dental health needs. 2. The dentist must respect the par ent’s role in the child’s dental treatment. Parents should be given an explanation of the ground rules. The dentist needs to talk with the parents alone to make clear to the parent his responsibilities. For in stance, it is necessary that a young child be brought to the office; that the older child be encouraged to keep appoint ments; that active help be given to a young child in home management pro cedures— brushing the teeth, reducing sweets, wearing appliances—because the young child cannot carry this responsi bility alone. But, by the same token, the dentist needs to understand that parents usually cannot carry the responsibility for home management of the adolescent’s dental problems because of the ado lescent’s normal thrust for independence. And the dentist needs to understand that parents may be ineffective in home man agement of even young children if the relationship between the parent and the child is already too conflictive. In these instances, as with the adolescent, the dentist must work directly with the child to win his cooperation. Parents should be kept informed of the child’s progress and response to treat ment—but not with an attitude that it is the parent’s fault that there are diffi culties. 3. It is important for the dentist to know when to be flexible about ground rules and other recommendations. A rela tively mature mother with a good rela tionship with her child may be able to meet the dentist’s recommendation that
there be no in-between-meal sweets. The overindulgent mother may find it ex tremely difficult to deny the child’s grati fication or to set limits, and she may be unable to resist the child’s wheedling. When the dentist understands this, he may be more flexible. He may suggest to mother that, if the child must have sweets, he should brush his teeth or that he may have all his sweets at one time and then brush his teeth. The dentist needs to show some flexibility too in rearranging an ap pointment, not as a regular practice, but as a special favor under special circum stances. 4. The dentist needs to realize that dental education of parents, like all edu cation, is a continuing process. With most parents it is not accomplished in a single session or in an occasional interview. It requires the dentist’s sustained, persistent efforts. A lapse on the part of the parent in following recommendations does not necessarily mean she is uncooperative. There are lapses in all learning. 5. It is essential that the dentist have some understanding of himself and of his role with parents. He needs some selfawareness in order to be freer to act— to do what is professionally sound and ap propriate as a dentist. He needs to under stand his meaning to parents; to be aware of his own characteristic ways of meeting the demands of parents; and to keep his focus on helping parents meet the dental health needs of their child. He needs to be clear in his own mind that his involve ment with parents is not for the purpose of exploring or treating the parents’ psy chological problems. In this connection I want to mention a case reported in the dental literature. It involved a 13-yearold adolescent girl with rampant decay and oral signs of nutritional deficiency. The dentist recognized that emotions and environment might be affecting her den tal health. Having observed the child and noted the mother’s cold and unsympa thetic face, which to him suggested cruelty, the dentist asked the mother
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bluntly, “ Why do you hate that child?” of children and their parents through such While the dentist in this particular case suggestions. surrounded the question with many Finally, dentistry, parallel with other cushions and offered to refer the mother health professions, is increasingly con for help, I submit it is not within the cerned not only with the diagnosis and dentist’s competence and responsibility to treatment of dental disease but with den explore attitudes or make interpretations tal health education and prevention. To enable dentists to be more effective in in this way. 6. The dentist is in a strategic posi their work with parents toward these tion to make referral of parents to appro ends, dentistry will need to give greater priate sources. It is very common for attention to the learning and teaching parents who have a good relationship of the psychology of interpersonal rela with the dentist to discuss with him their tionships by including programs of this child’s problems, and their own marital nature in the curricula of dental schools. 664 North Michigan Avenue and personal problems. It is important that the dentist not become involved in the personal life of the parent or interfere Presented before the M id-W inter meeting, C hicago in the parent’s interpersonal relationship Dental Society, February 5, 1964. *Administrative director, Child Therapy Program, In with his child. He can be an interested stitute for Psychoanalysis, Chicago; consultant, social service department, Veterans Administration, Hines listener but he is not trained to treat Hospital. !. Heist, P. Personality characteristics of dental stu the parent-child relationship or the dents. Educational Record 41:240 July I960. child’s emotional disturbance. Depending 2. More, D. M., and Kohn, N. Some motives for on the degree to which he is psychologi entering dentistry. Am. J. Soc. 66:48, I960. 3. Nachmann, Barbara. Childhood experience and cally attuned, the dentist may suggest vocational choice in law, dentistry, and social work. J. Counsel. Psychol. 7:243, I960. that parents seek help from competent 4. Kirk, Barbara A.; Cummings, Roger W., and Herbert R. Personal and vocational character sources. Many dentists have made a last Hackett, istics of dental students. Personnel & Guidance Journal, ing contribution to the emotional welfare Feb. 1963, p. 522.
Personal Responsibility • Self-indulgence— the principle o f pleasure before duty— is practiced across the length and breadth o f the land. It is undermining those attributes o f personal respon sibility and self-discipline which are essential to our national survival. It is creating citizens w ho reach maturity with a warped sense o f values and an undeveloped conscience. / . Edgar H oover. Chicago Sun-Tim es, O ctob er 10, 1962, p. 4.