SECTION 1

BEHAVIOUR MANAGEMENT- NON PHARMACOLOGIC

 Behavior is defined as the way in which an animal or person acts in response to a

particular situation or stimulus.

 BM in dentistry – building relationship with child , parent and dentist

 Very rewarding if dentist is trained to manage behavior, has proper mindset and
environment is conjucive

 Dentist and team have to be very caring

VARIABLES WHICH AFFECT A CHILD BEHAVIOR AT THE DENTIST

1. Dental environment

2. Dentist factors

3. Child Factors

4. Parent factors

A. DENTAL ENVIRONMENT
 It should be warm and simulate a homely environment
 Dental auxillary should be polite with the children and greet them warmly.
 The operatory can be made colorful and lively with posters, television, toys for children.
 A separate waiting room for children with comics, books, toys etc.
 Colors used, smell of surgery, sounds all have impact on childs response to treatment

 Snoezelen Environment- It is a multisensory adapted environment believed to reduce the

levels of anxiety, pain and unrest in patients.

 The physical environment consists of a partially lit room with special lights, relaxing music
and aromas.

 Use of this environment has been seen to be useful in children with special needs like
autism or mental retardation in stabilizing heart rate and reducing anxiety.

 Shapiro et al did a study where he produced a Sensory Adapted Dental environment (SADE)
based on the snoezelen environment. The SADE had dimmed lights of 30-40Hz for visual
stimuli, rhythmic background music for auditory stimuli and a dental xray vest placed on
patient for tactile stimuli

B. DENTIST FACTORS
 Categories of activities by which dentists can enhance cooperative behaviour in children:
 Data gathering and observation
 Structuring
  Empathy and support
 Flexible authority
 Education and training

 Data gathering includes collecting information by a formal /informal interview or a written

questionnaire from parent/child

 Observation is a continuous activity. Begins as soon as child enters the office and continues
through waiting room area, interaction with the auxillary, reactions to different stimuli and
objects in the dental office.

 This gives clues to the dentist as how to approach the child.

 Refers to guidelines of behaviour which are communicated by the dentist and his staff to
the child.

 With this children know what to expect and how to react.

 It is the capacity to understand and to experience the feelings of another without losing
one’s objectivity.

 This can be achieved by:

 -Letting the child express his feelings of anxiety and fear, but not allowing temper-
tantrums.

 -Telling them that you understand their reactions to this new environment.

 -Comforting by words, touching or patting.

 -Encouraging good behavior

 This involves educating both child and parent regarding good dental health and stimulating
them to make necessary behavioural changes to achieve these goals.

 Previous bad experience with a dentist wearing a white attire

 may evoke fear in future situations with people wearing similar outfit.

 short- less than 30 min.

 Long - upto 45 min

 Should be in early morning, not in their nap time.

 A letter or a phone call informing about the appointment.

 Helps reduce anxiety especially of the mother.

C. CHILD FACTORS
 Growth and development of child.
 Nutritional factors.
 Past Dental & Medical Experience.
 School environment
 Socioeconomic status

 Any abnormality in normal growth and development may have led to feeling of rejection and
inferiority.

 Mentally handicapping conditions.

 Very young child- under 3 yrs- lacks intellectual maturity to accept treatment.

 Nutrition can Affects milestones of biological and cognitive development

 Studies have found irritable behaviour associated with increased intake of sugar.

 Number of past visits to dentist/doctor not important.

 Quality of visits is important.

 pain or discomfort experienced at previous visit

 History of anxiety and fear associated with needles and the dentist

 SCHOOL ENVIRONMENT

 50% of child’s development in school.

 Teachers and seniors serve role models.

 SOCIOECONOMIC STATUS

 HIGH:

 Child may be spoiled.

 Psychological development normal.

 LOW:

 Child is often neglected

 May not value dental health.

 D. PARENT FACTORS
 Home environment
 Family and peer influence
 Maternal attitude and behavior

 Home is the first school where a child learns to behave.

FAMILY AND PEER INFLUENCE

 Family conflicts

 Influence of elderly and older siblings.

 Status of child in family.

 Mother-child relationship is more intimate

 Children usually have more contact with mothers

Types of maternal attitudes

 Over Protective and dominant

 Over Indulgent
 Under affectionate
 Rejecting
 Authoritarian

Over-protective

 The usual feeling of love by mothers for children, when exaggerated leads to
overprotection,which is harmful for normal psychological development of the child
 Causes may be-
 A history of delayed conception
 A history of miscarriage
 A history of no other sibling
 A history of handicapping or diseased condition in the child
 A history of paternal absence through death or divorce.
 Signs:
 Excessive care to child continuing past the usual age
 Excessive concern in child’s routine problems.
 Mother is constantly involved in child’s daily activities.
 Child behaviour :
 Submissive
 Shy
 Anxious
  Lacks self confidence
 Lacks coping abilities
 Are cooperative
 Polite , obedient and disciplined
 Management:
 Create self confidence
 Familiarize with dental office

Overindulgent

 This behavior may be associated with overprotection

 Or may be the dominant trait
 Management difficult in dental office
 Child behavior-
 Usually a spoiled child
 Aggressive and obstinate
 Demanding
 On denial of wishes throws temper tantrums
 Are difficult to make friends
 Demands attention

Rejection

 It is an extreme behavior where child is totally neglected

 Causes:

o Any circumstance when child is unwanted

 Child behavior

o Lacks feeling of worthiness

o Aggressive

o Overactive

o Disobedient

o Tries to gain attention by any means

 Very difficult dental patients

PARENTAL PRESENCE IN ROOM

 It is appropriate for parent to be in room during a childs treatment

 Useful especially for younger kids
  Coach parents on how they can be useful during treatment
 If parent cant support child its ok for them to stay in waiting room
 Parental access should never be denied

SECTION 2

Psychology theories-

 Cognitive Development – Piaget

 Erikson

 Skinner- Learning theory

 Temperament

Piaget Theory

 In 1936 Piaget was first to do a systematic study of cognitive development

 Children born with basicmental structure on which all subsequent learning and knowledge is
based

 Looks at developing processes in a child due to biologic maturation and environmental

experience

 Schemas – Building blocks of knowledge

 Adaptation processes - Assimilation, Accommodation, Equilibration

 Stages of Development- Sensorimotor

 - Preoperational

 -Concrete Operational

 - Formal Operational

Schemas

 They are basic building blocks which allow us to form mental representation of world

 It’s a way of organizing knowledge

 Units of knowledge each relating to aspects of life

 Eg. A person has schema of buying meal at restaurant

 Schema stored form of pattern of behavior like look at menu, order food, eat, pay bill

 Whenever u r in restaurant u retrieve schema from memory and apply to situation

 Eg. Touch child’s lip sucking reflex kicks in- sucking schema

 touch baby’s thumb they grip object

 ASSIMILATION-

 Using an existing schema to deal with a new object of situation

 ACCOMODATION-

 Existing schema does not work and needs to be changed to deal with a new object or
situation

 This is what moves development along

 In EQUILIBRATION child’s schema can deal with most new information through assimilation

 An unpleasant state of disequilibrium occurs if new information cant be fitted into existing
schema

 Eg . Childs first dental visit, injection, dental sounds

 Equilibration drives the learning process as we don’t like frustration




Sensiromotor(birth -2yrs)

pre operational(2-7yrs)
 FORMAL OPERATIONS (11YRS and above)

 Child develops ability to think of abstract concepts

 They use logic

 Can test a hypothesis


DESCRIPTION DENTAL IMPLICATIONS
SENSIROMOTOR STAGE Birth -24mths infants use senses and motor abilities to understand Advice regarding tooth eruption, initial oral hygiene
minimal verbal communication Child has limited ability to understand dental work
child aware of environment oral examination can be attempted

PREOPERATIONAL STAGE 2-5YRS Child begins to use langauage Tell stories during treatment it may help to distract
little logical reasoning use of lots of praise when child does well
preference of boy girl objects matter give child achoice in treatment

CONCRETE OPERATIONAL6-11YRS Children show increased logical reasoning skills child normally cooperative and can be treated in parents absence
see world from different view point new fear can develop at this age so may be unccoperative
few abstract ideas avoid embarrassing them or critisizing them
give clear truthful explanations
FORMAL OPERATIONS 12YRS + Children think abstractly and hypothetically treat adolesent as own person, independent from parent
analyze and reason talk of some none dental topics in adult way
emphesize importance of self dental care to maintain smile

ERIKSON THEORY

 Originated in the 1950

 His theory looks at psychosocial stages

 He looks at role of culture and society in influencing development

 Belief that personality develops in a predetermined order and builds upon each previous
stage

 This leads to integrated set of life skills and abilities that function together within individual

 Erikson assumes each stage has a crisis associated with it



BIRTH -1.5YRS

1.5-3yrs
3yrs-5yrs
 5yrs-12yrs

12-18yrs

Skinners Learning Theory

 Believed best way to understand behavior is to look at at the cause of an action and its
consequences
  Operant conditioning

 Looks at intentional actions that have an effect on the surrounding environment

 Identified 3 responses that follow behaviour

1. Neutral operant- response does not increase or decrease chance of behavior being repeated

2. Reinforcers- Response from environment that increases chance of behavior being repeated.
Positive or negative

3. Punisher- response that decreases chance of repeat behavior. Punisher weakens behavior

Temperament

 Easy temperament – easily adapts, approaches new situations well, positive mood
 Difficult temperament- withdraws from new environment, negative emotional
expressions of high intensity
 Slow to warm up temperament- labelled as shy. Adapt slowly and can have negative
emotions.

Wrights Classification

 Cooperative – most patients cooperate, they are relaxed, minimal apprehension,

enthusiastic

 Lacking cooperative ability- very young child who cant communicate, children with certain
disabilities who cant communicate appropriately

 Potentially cooperative-child’s behavior can be modified to become cooperative. Child has

capability to cooperate

- Hysterical - defiant -tense cooperative -shy -whining

 ]

SECTION 3

Non-Pharmacologic BM

1. Communication – Voice control

2. Behavior Shaping - TSD

- Positive reinforcement

- Systemic Desensitization

-Modeling

3. Behavior Management - Retraining

-Distraction

-Aversive conditioning

-Parental Presence

-Restraint
 1. Establish communication – initiate communication by a compliment then ask questions with
yes and no answer

2. Establish communicator – nurse normally communicates with child from reception to

surgery. Dentist then takes over. Avoid both nurse and dentist talking same time it confuses
child

3. Message clarity- transmitter is dentist child is receiver. Clarity of message includes use of
euphemisms appropriate to child’s age

4. Active listening- effective especially for older kids.

5. Appropriate responses- child first visit is anxious then dentist shows extreme displeasure.
That may be inappropriate

Voice control-

 Sudden firm commands get child’s attention

 Slow deliberate voice

 Effective when used in conjunction with other communications

 Voice modulation , tone or volume control to gain patients attention

 Repeat command to ensure child understands

BEHAVIOR SHAPING

 Based on the principles of social learning

  PROCEDURE WHICH VERY SLOWLY DEVELOPS BEHAVIOR BY REINFORCING SUCCESSIVE
APPROXIMATIONS OF THE DESIRED BEHAVIOR UNTIL THE DESIRED BEHAVIOR COMES TO BE

 Most behavior is learned and learning is due to establishing a connection between a

stimulus and a response

 Also called stimulus response theory

 Shaping behavior involves teaching child to behave

 Procedure explained in step by step fashion to child

 Child needs to cooperate and communicate to absorb information given

TSD

 Cornerstone of behavior guidance

 It is component of Behavior shaping

 TSD is a series of successive approximations

 State general goal and task to child at beginning

 Explain necessity of procedure

 Give explanation at childs level

 TSD is a series of successive approximations

POSITIVE REINFORCEMENT

 Reinforcement works well with TSD

 Reinforce appropriate behavior

 Immediate reinforcement reduce fear related behavior

 Tangible or social reward in response to desired behavior

 Give small tokens tooth brush, stickers, smiley stamp, balloons

 Negative reinforcement is the opposite use stern voice to reprimand bad behavior

SYSTEMIC DESENSITIZATION

 Reduce anxiety by introducing treatment which provokes least anxiety first

 Introduce ones which provoke more anxiety as time progresses

 

MODELLING

 Theory by Bandura et al (1969)

 Children learn by observing and imitating

 Provide an example or demonstration about how to perfom a behavior

 Live modelling involves watching a sibling or parent being treated

 Filmed modelling can be done as well

 Use of posters

RETRAINING

 Children who need retraining approach dental office with negative behavior and
apprehension

 Behavior may be due to past bad experience, improper parent or peer orientation

 Determine source of problem

 Avoid problem by de emphasizing or distraction

 Build a new series of associations in the child

 Eg. Try NO it offers a difference

DISTRACTION

 Divert child’s attention from unpleasant dental visit redirect to something else

 Child rotate foot during la, story book, music, avd

 

AVERSIVE CONDITIONING-HOME

 Hand over mouth ( HOME) is used to gain the attention of a very poorly behaved child

 Used to establish communication and cooperation to allow treatment

 Not used routinely but it’s a last resort usually children aged 3 – 6yrs

 Departure from accepted application of HOME can expose dentist to liability

PARENTAL PRESENCE

 Presence of parent in room can assist dentist to manage behavior

 Parents also assist by giving informed consent

 Presence normally reassures child and the parent

 Parent helps in communicating especially with disabled child

 Very young children normally require attendance of parent

 If parent counter productive by saying wrong things may ask them to leave

 Parent has to comply with what dr says

 At times if parent moves out of child’s line of vision it helps

 Parent presence usually based on office policy

RESTRAINTS, PROTECTIVE STABILIZATION

 Bite blocks
 Restrict patients freedom of movement to decrease risk of injury. Papoose board used in
very young, retarded children
 Passive- Wraps, papoose board
  Active is when parent staff hold child to avoid movement

SUMMARY

Tell–show–do Informing, then demonstrating, and finally performing part of a procedure

Shaping Successive approximations to a desired behaviour
Positive reinforcement Tangible or social reward in response to a desired behaviour
Systematic desensitization Reducing anxiety by first presenting an object or situation that evokes little fear,
then progressively introducing stimuli that are more fear-provoking"
Distraction Ignoring and then directing attention away from a behaviour, thought or feeling, to something else
Fading Providing external means to promote positive behaviour and then gradually removing the external control
Playful humour Using fun labels and suggesting use of imagination

CONCLUSION

 BM techniques form part of Pediatric dental treatment

 Routinely more than one method is used at any one appointment

 When non pharmacologic BM techniques fail need to use pharmacologic methods may arise

 A holistic approach is needed to manage a child well