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BDJOpen 2017;10.1038/bdjopen.2017.18http://dx.doi.org/10.1038/bdjopen.2017.18

For many years dental practitioners have been providing stickers to paediatric patients as a form of positive reinforcement to encourage cooperative behaviour. However, does the reward of stickers actually lead to positive reinforcement in children?

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In this paper, James Coxon and co-authors looked at the opinions of children aged 4–8 years in relation to their desired reward for attending the dentist. This highlighted that there was no clear favourite reward among children but a 'sticker' reward was never chosen. So, why is this still our reward of choice if it is clearly not desirable?

The research identified that the most popular reward choice for children in divided age groups was as follows:

  • 4-5 years: bubbles (33%), princess badges (24%) and dino glider (19%)

  • 6-7 years: highlighter (46%), egg (18%) and alien slingshot (18%)

  • 8 years: Marvel figure (36%) and dino egg (21%).

An issue with this research is that different reward choices were provided to the different age groups, meaning a variety of 'favourable' rewards have been identified. It may not be feasible to offer this range of rewards in general dental practice; equally some of the rewards given are quite 'current' (eg Marvel, Despicable Me) but keeping on top of trends may be a challenge.

This study also looked into whether or not caregivers could accurately determine what their child would choose as a reward. Caregivers only agreed an average of 34% of the time, and disagreement was seen more often as the child got older. Therefore, this indicates that healthcare professionals are also unlikely to determine what an effective reward would be to achieve positive reinforcement. Ensuring a small range of reward choices at the dentist would be beneficial, opposed to just handing over a sticker with Elsa or Spiderman on it. This increases the likelihood that the reward is relevant and of importance to the child and encourages repetition of the positive behaviour displayed in the appointment.

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We are now aware that a more positive reaction is gained from children when they receive rewards other than stickers. However, we need to know if this is really effective in developing cooperation in these patients. Are these novel rewards helping in providing successful, cost-effective paediatric dentistry or are we just bribing children to behave?

Sophie Bryant, Dental Student, University of Leeds

Expert view Dr Zoe Marshman Reader/Honorary Consultant in Dental Public Health School of Clinical Dentistry, Sheffield

Child dental anxiety is common with potentially significant impacts on children's oral health, their quality of life and occupational stress for the dental team. Non-pharmacological approaches available to dental teams when caring for dentally anxious children range from simple behavioural techniques, such as positive reinforcement and tell-show-do to more complex cognitive behaviour therapy.1 Positive reinforcement in general dental practice often involves the use of praise and stickers given to children for good behaviour. When used in this way children are rewarded and encouraged to develop positive behaviours for future visits.

This paper challenges the use of stickers as the preferred reward for children when visiting the dentist. A sample of over 50 children aged 4-8 years attending a dental practice where asked to choose which reward they would prefer from 10 different options. The rewards were low cost toys, badges and included stickers as an option. Children from the youngest age group to the oldest said their preferred rewards were bubbles, highlighter pens and comic book figures. No children said they preferred stickers.

The authors highlight the need for further research into the timing of giving the reward which raises questions about whether stickers are actually given as rewards for positive behaviour, such as completing the treatment as planned, or are just given out routinely to all children or whether they are in fact used as bribes once children start exhibiting negative behaviour?

Interestingly, parents were found not to be well placed to predict which reward their child would choose. The findings of this study suggest that to promote child-centred care children should be involved both in the selection of the choice of rewards on offer and also be able to choose the reward they would like themselves. The benefits of providing dentally anxious children with choice and indeed control during dental treatment have been found to successfully reduce dental anxiety.2

Author Q&A Tim Newton King's College London Dental Institute

Why did you choose to study this?

We had previously undertaken research which suggested some gaps in the understanding of the psychological principles underlying the use of rewards amongst dental practitioners. This research explores the type of reward that might be appropriate for children of different ages.

Did anything surprise you?

When given a choice children clearly do not choose stickers as a reward which, while it didn't surprise us, may be surprising to practitioners. What is surprising is the low levels of agreement in reward choice between children and parents.

What would you recommend dentists provide on the basis of this research?

Dentists, or the reception team, should offer a range of possible rewards to children before they enter the surgery, making it clear that the child will receive the reward if they complete their appointment successfully. The chosen reward should only be given if the child manages the behaviour that was required of them. Note that the reward will be given for the behaviour not a value judgement, so for example 'That's amazing, you had your fissure sealant' or 'Well done, you sat really still during the examination' would be examples of linking reward to behaviour whereas 'Well done, you were good today' is a value judgment and does not make it clear what the child did that was 'good'.