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Working with Children: From Compliance to Collaboration

Compliance is a concern that we as orthodontists face daily. Technical progress has been made in the last decade or so with the development of so-called "non-compliance" devices, but patient behavior remains an issue. In this month's column, Mary Osborne and Joan Unterschuetz present a behavioral method of working with children. As they explain, compliance is just the first step; engagement is the goal, and, depending on the patient's age, collaboration in treatment is the outcome.

In today's world, children are constantly being told what to do--in school, in extracurricular activities, and at home. What a pleasant surprise it is to them when they are asked their opinions, and what a relief for us when they voluntarily take part in the orthodontic process. Truly a win-win situation.

Several years ago, my staff and I worked with Ms. Osborne and Ms. Unterschuetz to develop the new set of skills and attitudes they outline in this article for age-appropriate engagement. It had a positive impact on each member of our team and changed the entire practice environment. Now, we are consistently complimented on how well we work with children, and I believe we have added value to our orthodontic service.


Working with Children: From Compliance to Collaboration

Patient compliance is an aspect of treatment that orthodontists consistently find to be among the most challenging, and sometimes the most frustrating. Everyone knows how difficult it is to get young people to follow instructions about orthodontic appliances. What you may not realize is that compliance is not always the most appropriate goal.

You can become more effective in dealing with children at various stages of development if you learn to understand age-appropriate differences in behavior and motivation. As children develop physically, they also change emotionally and in how they learn. The learning process is a continuum, with different levels of participation that are appropriate at different times.

Psychologists have found that, developmentally, most young people progress from compliance (between ages 8 and 10) to cooperation (ages 12-14) to collaboration (ages 14-16). Orthodontists and staff members can develop the attitudes and the skills to engage children at the highest level of which they are capable, rather than the lowest. Of course, these phases vary significantly from child to child; our challenge is to engage each child at the level to which he or she currently aspires.


An 8-year-old is likely to want to please adults. At this age, children are likely to comply, to do what they are told. Approval from parents, teachers, even the orthodontist, is important to them. They go to soccer practice because an adult tells them they should. When you watch this age group playing soccer, they are often paying more attention to their coach or their parents than to their teammates--or the ball.


A 12-year-old is generally more peer-focused. These children can actively cooperate and do their part. The acknowledgment of their friends becomes more important to them, but they are still not future-focused. In sports, they do not really understand that practice will improve their performance or the success of the team. They are not skilled at developing a plan, because they have not yet realized that their behaviors have an effect. They are more likely to go to practice because everyone else does. In a soccer game at this age, they are all individual players, primarily concerned about their own performance.


A 14-year-old is capable of collaborating in creating strategies for success. At this age, children are better able to grasp that what they do has an effect on the outcome. In athletics, they begin to interact more as a team. They begin to see the relationship between practice and performance. They understand plays and tactics for winning a game.

Attitudes and Skills

At all ages, of course, there are differences in how particular young people will respond to information. Sixteen-year-olds have the widest variation in their ability to participate in the process; on any given day, they may swing between compliance and collaboration. The challenge of the orthodontic team is to tune in to where each child is developmentally and to meet him or her at that level. Compliance has traditionally been seen as the goal, but in fact it is the lowest level of engagement. You can develop the attitudes and skills to help you meet young people at their highest level of participation.


  • Respect the individuality of each child. Trying to accommodate all children to a one-size-fits-all learning model does not recognize their individuality. The more you can become curious about what makes each child unique, the easier it will be to work with them and help them learn.
  • Develop curiosity about the unique resources required to be successful with each child. Solving the behavioral riddle with every young person is both challenging and rewarding.
  • Form appropriate expectations about what you will achieve together and how you will achieve it to create healthy relationships. Clear expectations free you and the patient from disappointment and frustration.


  • Getting permission from young people is a simple, but important, step in gaining their cooperation and trust. Young people are used to being told rather than asked. If you begin with asking instead of telling, they are likely to be more open and interested in information and instruction. If you want to help them take responsibility for their health, you must treat them as responsible individuals able to make choices. Get permission to look in their mouths or to take x-rays or impressions. Saying, "I'd like to have a look in your mouth now, Johnny; is that OK with you?" is a simple way to demonstrate respect.
  • Asking questions helps you learn about each child before you begin giving information. Avoid asking, "Are there any questions?" or "Do you understand?" Instead ask them what they know about orthodontics, what they have heard, what they are concerned about. Listen for clues about what is important to them. Young people are capable of having conversations beyond chatting about school and sports. You can also ask parents what they know about how their children learn best and what seems to motivate them. The more you know about their lives, the more effective you will be.
  • Encouraging emotional development enhances the learning environment. Children (and adults) learn best when they feel accepted and safe, emotionally as well as physically. Look for every opportunity to contribute to their self-esteem. Help them identify successes they have had in their treatment and in other areas of their lives. Don't be too quick to point out the places they missed when they brushed. Find an area in which they have been effective, and help them see the difference. Focus on the times they did wear the headgear or elastics instead of the times they did not. Build on successes instead of calling attention to failures.
  • Describing instead of evaluating the existing conditions takes you out of the role of judge and into a more collaborative relationship. There is a big difference between telling a child whether he or she is doing a good job and describing what you see. Saying, "You need to brush better" is evaluative. "I see some plaque along the gum line here" is descriptive. "Would you like me to help you be more effective in this area?" is supportive.
  • Challenging at suitable skill levels contributes to success. If a task is too difficult, the child will become frustrated; if it is too easy, the child will be bored. Pay attention to how well children do at one task before suggesting another one that is more difficult. If they are not able to perform at the level necessary for the task, help them find away to include an adult in the process. You might say, "I know flossing is hard for you, Susie. Is there someone at home who could help you?" Let the child make the invitation to the appropriate person, and offer to help that adult learn how to do the task in a way that is comfortable for the child.
  • Creating age-appropriate strategies allows a young person to feel successful, and you can then build on those successes.

Compliant stage: At this stage, enthusiastic praise from adults is highly motivating. Congratulate them on their efforts, or give them gold stars or other rewards to help them mark their progress and feel good about themselves.

Cooperative stage: Keep the learning experience tightly focused with this group. Give them detailed instructions and manageable goals. You might suggest that they watch a specific tooth to see how much it moves. A tooth journal can be a useful tool at this age. Or you might ask them to call and report on their observations. Help them learn to take responsibility.

Collaborative stage: With this group, you can give them information and involve them in creating strategies for success. You might tell them, "It takes 21 days to form a habit. What would work for you in creating this habit?"


At any age or stage of development, engagement is the goal. In education, engagement has been described as "that which occurs when the student is working at least as hard as the teacher". Ask yourself how often you feel as though your patients are working as hard as you are. When you find yourself doing all the talking, stop. Picture the gears on a bicycle. Remember that if the gears are not engaged, you are going nowhere, no matter how hard you pedal.

At all levels of development, young people must be engaged before they can learn. Ultimately, you will save time by taking the time to engage them in the process. Ask a question that requires a response more thoughtful than a yes or no. Listen carefully to the response. Hold it with respect. Make sure your expectations are appropriate for the child's stage of development, and be prepared to modify your expectations if they are not.

You have much to learn from the young people you treat. How would your practice life be different if you could help children learn to actively collaborate in their treatment, instead of just complying with instructions? Engaging them in their orthodontic care can make a contribution to their lives that goes beyond straight teeth.

  • MARY H.
  • JOAN

Ms. Osborne works at MHO Resources, 1564 Alki Ave. S.W., Suite 303, Seattle, WA 98116; MHOResources@msn.com. Ms. Unterschuetz works at Continuums Consulting, 3000 Riviera Blvd., Malaga, WA 98828; joanshootz@aol.com.





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