Child behavior-lec-4-beh.-manag-2015

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PEDO. 5TH Y. 2016- 2017 Lec. -4-
Dr. Sami MalikAbdulhameed
BEHAVIOUR MANAGEMENT IN PEDIATRIC DENTISTRY
(STRESS REDUCTION ) OR BEHAVIOR MANAGEMENT
Behavior Management techniques can be broadly classified as:
*Non-Pharmacological Techniques.
*Pharmacological Techniques
 No anesthesia/analgesia
 Local anesthesiainjection
 Oral (enteral) medication
 Inhalationagents(nitrousoxide/oxygen)
 Intramuscularinjection
 Intravenousagents
 General Anesthesia
Stress ReductionProtocol:Normal, Healthy Patient
Non-Pharmacological Techniques.
*Minimize waitingtime
*Psychosedationduringtherapy,asneeded
*Adequate paincontrol duringtherapy
*Lengthof appointmentvariable
*Postoperative pain/anxietycontrol
Stress ReductionProtocol: Medical Risk Patient
*Recognitionof the medical risk
*Medical consultationasneeded
*Morning appointment
*Preoperative andpostoperative vital signs
*Psychosedation duringtherapy,asneeded

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*Adequate paincontrol duringtherapy
*Lengthof appointmentvariable
*Postoperative pain/anxietycontrol
1. Communication
2. Behaviorshaping(modification)
a. desensitization
b. modelling
c. contengencymanagement
3. Behaviormanagement
a. audioanalgesia
b.biofeedback
c. voice control
d.hypnosis
e.humor
f.coping
g. relaxation
h. implosiontherapy
i.Aversive conditioning

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1- Communication
 Verbal [establishment of communication,
establishment of communicator ,message clarity,tone]
 Nonverbal [Multi sensory Communication]
NONVERBAL COMMUNICATION
Reinforcement of behavior
through provider contact,
posture and facial expression
• Enhances the effectiveness of other communicative management techniques
• Culturally sensitive
• Recognized behaviors that convey information
• Facial expression
• High Five
• Reciprocal Social Interaction
• Eye gaze
• Turn taking
• Respect personal space
• Respond to social signals
Communicating with children
 Effective communication with children is critical for gaining the child’s cooperation to receive
dental care.
1. Tell Show Do
2. Reflective listening
3. Self-disclosing assertiveness
4. Descriptive praise.
 Effective communication is a primary objective.
 Communicate in two basic ways:

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1. verbally: using therapeutic communication skills, as well as talking about school
activities, pets, articles of clothing, children’s television programs, books, muppets
2. 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.
• It is essentially a “behavior shaping” strategy.
TELL :- before ,during ,after
• TELL… using euphemisms
(substitute language)
• Be honest in your TELLing!
Childrenese’ Terms for Dental Equipment
 Slow handpiece: ‘buzzy bee’
 Air Rotor: ‘whizzy brush’
 Triplespray/inhalation sedation: ‘magic wind’
 Local anaesthetic: ‘jungle juice’ or ‘sleepy juice’
 Giving a local: ‘put your teeth off to sleep’.
 Rubber Dam: ‘raincoat’
 Rubber Dam Clamp: ‘clip’ or ‘button’
 Rubber Dam Frame: ‘coat hanger’
SHOW
• SHOW (demonstrate) the child what will happen, 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.

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• 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!
Tell-show-do
 The technique involves verbal explanations of procedures in phrases appropriate to the
developmental level of the patient (tell);
 demonstrations for the patient of the visual, auditory, olfactory, and tactile aspects of the
procedure in a carefully defined, non threatening setting (show);
 and then, without deviating from the explanation and demonstration, completion of the
procedure (do).
 The tell-show-do technique is used with communication skills (verbal and nonverbal) and
positive reinforcement.
Tell-show-do
Objectives:
 1. teach the patient important aspects of the dental visit and familiarize the patient with the
dental setting;
 2. shape the patient’s response to procedures through desensitization and well-described
expectations.
Acclimatisation…getting familiarized
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 is being treated
humanely.
 Enhancing control
 Here the patient is given a degree of control over their dentists' behaviour through the use of a
stop signal. Such signals have been shown to reduce pain during routine dental treatment and during
injection. The stop signal, usually raising an arm, should be rehearsed and the dentist should respond
quickly when it is used.

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DENTAL TERMINOLOGY WORD SUBSTITUTES
 rubber dam rubber raincoat
 rubber dam clamp tooth button
 rubber dam frame coat rack
 sealant tooth paint
 topical fluoride gel cavity fighter
 air syringe wind gun
 water syringe water gun
 suction vacuum cleaner
 Alginate pudding
 study models statues
 high speed whistle
 low speed motorcycle
2-Behavior shaping
By definition, it is that procedure which very slowly develops behavior by reinforcing successive
approximations of the desired behavior until the desired behavior comes to be.
: Stimulus – response (S-R) theory
Systematic Desensitization ..exposure to hierarchy of fear producing stimuli
Desensitization : (joseph Wolpe)
Systematic Desensitization ..exposure to hierarchy of fear producing stimuli

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Modelling
 Bandura (1969) :- Live ,Filmed ,Posters ,Audiovisuals
 Allowing the patient to observe one or more individuals [models]
 Patient frequently imitates the models
Distraction
 Diverting the patient’s attention from what may be perceived as an unpleasant procedure.
Music , Video ,Talking ,White noise ,Hypnosis ,Breathing
Objectives of Distraction
 1. decrease the perception of unpleasantness;
 2. avert negative or avoidance behavior.
 Indications: May be used with any patient.
 Contraindications: None.
Contingency management (Reinforcement )
 Positive reinforcer
 Negative reinforcers :- Social ,Material ,Activity
Reinforcement :- ‘isthe strengtheningof a pattern of desired behaviour & increasing the probability of
that behaviour being displayed again in the future’
Types ofReinforcement
 Positive Reinforcement
 Negative reinforcement

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 Usual approach usedin dentistry.
 Appropriate behaviour exhibitedbythe child resultsin the child receivingsome form of positive
‘reinforcer’.
Reinforcer:
 Material: toy, badge.
 Social stimuli:verbal praise, approval,tapping of the shoulder.
Whenshouldpositive reinforcementoccur?
 Directly after the appropriate behaviour has occurred.
 Known to increase their value.
*Positive reinforcement
 to give appropriate feedback.
 to reward desired behaviors and thus strengthen the recurrence of those behaviors.
 Social reinforcers include positive voice modulation,facial expression, verbal praise, and
appropriate physical demonstrations of affection by all members of the dental team
Nonsocial reinforcers include tokens and toys.
Objective: Reinforce desired behavior.
Praise
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.
PRAISE
*Powerful positive reinforcer that helps children learn *Tell them what they can do!
*Verbal *Nonverbal (Visual, auditory, touch (high five) *Praise the behavior that you want repeated
*Be specific and simple

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REWARDS
*Closely tied to a performance criteria *Rewards are tangible *Set rule prior to desired behavior
*Age appropriate: stickers, tokens, computer /game boy time *Don’t give it ,Select and save for next
visit
*Negative Reinforcement
 ‘involves removal of an unpleasant stimulus as soon as the required behaviour is achieved’.
 Often confused with punishment.
 Punishment: where a negative stimulus (usually unpleasant) is applied to a wrong response.
 E.g. Hand-Over-Mouth (HOM).Is controversial & needs written consent from parent
Negative Reinforcement:
Negative Re-inforcer by Stokes & Kenndy 1980 is one whose contingent withdrawal increases the
frequency of behavior.It is usually the termination of an aversive stimulus.e.g.:withdrawal of the mother
S E P (selective elimination of parent)
3- Behavior Management
AVERSIVECONDITIONING
Aversive Conditioning
Stern
look
Firm
voice
HOM
Range of Negative Stimuli
Voice Control
Voice control is a controlled alteration of voice volume, tone, or pace to influence and direct the
patient’s behavior.
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.

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 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.
Objectives:
1. gain the patient’s attention and compliance; 2. avert negative or avoidance behavior;
3. establish appropriate adult-child roles.
HOME
 Redirect inappropriate behavior.
 Hand is gently placed over the child’s mouth and behavioral expectations are calmly explained.
 Maintenance of a patent airway is mandatory.
 Upon the child’s demonstration of self-control and more suitable behavior, the hand is removed
and the child is given positive reinforcement.
HOME
Indications:
A healthy child (Able to understand and cooperate), but who exhibits hysterical avoidance behaviors.
 Contraindications:
 1. children who, due to age, disability, medication, or emotional immaturity are unable to
verbally communicate, understand, and cooperate;
 2. any child with an airway obstruction.
Several variations of home:

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*HOMAR: HOM with airway restricted *HOM and nose with airway restricted
*Towel held over mouth only *Dry Towel held over mouth and nose
*Wet Towel held over mouth and nose
Informed consent
 All management decisions must be based on a subjective evaluation weighing benefit and risk
to the child.
 It is important that the dentist inform the legal guardian about the nature of the technique
 Communicative management, requires no specific consent.
VC/HOM GOALS – SAFETY
• Redirect the child’s attention, enabling communication with the dentist so appropriate
behavioral expectations can be explained (rules and roles)
• Stop avoidance behavior and help the child gain self-control
• Ensure the child’s safety in delivery of quality dental treatment
• Eliminate the need for parental sedation or general anesthesia
Selective exclusion of parent (SEP)
 Full parental consent.
 Explanation of the need.
 Children between 4-7 years.
 Contraindicated in any child incapable of understanding what is being asked of them.
 Parent should be at such a position where he/she out of sight of patient but can hear
what is going on in the setting.
 Should be called in discreetly as the child’s behaviour improves to be present as a passive
observer.
PARENT PRESENCE – ABSENCE
Objective: Set rules in the interview
• Remove competition for child’s attention and compliance
• Prevent negative or avoidance behavior
• Enhance trust

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• Tool - mommy in - mommy out (age appropriate
• Child takes on the role of the victim
Behavior management
a.audioanalgesia: white noise b. biofeedback: detect physiological processes
c. voice control d. hypnosis: altered state of consciousness
e. humor: f. coping: signal system g. relaxation: h. implosion therapy i. Aversive conditioning
Retraining
 To review and retrain the response to a given set of stimuli
Acupuncture on Dentistry
Acupuncture is a medical treatment developed in China in which complaints are treated by inserting fine
needles at various points on the body called acupuncture points. These needles can then be stimulated by
hand or heat. Acupuncture has been used for over three thousand years but it is only over the last twenty
years that it has begun to be accepted in mainstream Western medical practice. It is now increasingly
popular in the West and may be used to treat a wide range of medical conditions. There are also
alternatives to basic acupuncture available, e.g. electro-acupuncture and transcutaneous electrical nerve
stimulation (TENS).
The main application for acupuncture is in the treatment of musculoskeletal problems but it has also
been found useful in stress management and is also suitable for treating a number of dentally related
problems. It has been suggested that acupuncture is a very refined way of affecting the central nervous
system, of altering its responses in a selective manner. Like an old telephone exchange, insertion of the
needles connects certain pathways, throws certain switches and blocks other lines of communication in
a delicate and specific manner
Electrical Dental Anaesthesia (EDA) on Dentistry
EDA can be used in a number of ways. It can provide localised anaesthesia for restorative dentistry (e.g.
fillings) and can be used on its own instead of a local anaesthetic (injection in the gum) in some patients,
or in combination with some form of sedation, e.g. inhalational sedation, in other patients. It is therefore
useful in needle-phobic patients and those who do not wish to have the prolonged feeling of numbness
which follows conventional local anaesthesia. It is also useful in patients who cannot have a conventional
local anaesthetic e.g. who are allergic to them or who have a medical condition which means they are best
avoided. EDA tends to be more reliable when used on front teeth than on back teeth. It has also been used
in combination with inhalational sedation for the extraction of deciduous teeth in children. Its use for
extraction of teeth in adults is not proven and your dentist is very likely to advise a conventional method
of pain control for this. EDA can be used to reduce the discomfort of an injection in the gum of local
anaesthesia. It can also be used to help with painful extra-oral conditions such as temperomandibular joint
disorders.

Child behavior-lec-4-beh.-manag-2015

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