Behavior Management in Pediatric Dentistry PDF

Behavior management Dr. Hiyam Salah Behavior management is the means by which the dental health team effectively and efficiently performs treatment for a child and, at the same time, instills positive dental attitude. PREAPPOINTMENT BEHAVIOR MODIFICATION Psyc...

Behavior management Dr. Hiyam Salah Behavior management is the means by which the dental health team effectively and efficiently performs treatment for a child and, at the same time, instills positive dental attitude. PREAPPOINTMENT BEHAVIOR MODIFICATION Psychologist have developed many techniques for modifying patients’ behaviors by using principles of learning theory. These techniques are called behavior modification. Usually they are thought about in conjunction with dentist- patient intra operatory relationships. However, pre appointment behavior modification, as it is used here, refers to anything that is said or done to positively influence the child’s behavior before the child enters a dental operatory. Several methods of pre appointment behavior modification are recognized. Films or videotapes have been developed to provide a model for the young patient. The goal is to have the patient reproduce behavior exhibited by the model. On the day of the appointment, or perhaps at a previous visit, the new pediatric patient views the presentation. Pre appointment behavior modification can also be performed with live patient models such as sublings. Other children, or parents. Another behavior modification method involves pre appointment mailings. Precontact with the parent provide directions for preparing the child for an initial dental visit. Use of verbal and non-verbal communication to promote positive behavior in children 1. Respect. 2. Show interest in the child as an individual. 3. Share free information. 4. Give well-stated instructions. 5. Communicate at the child’s level. 6. Focus on the positive. 7. Show ethnic, and gender sensitivity. 1  PEDIATRIC DENTAL PATIENTS A major difference between the treatment of children and the treatment of adults is the relationship. Treating adults generally involves a one-to-one relationship, that is, a dentist- patient relationship. Treating a child, however, usually relies on a one- to-two relationship among dentist, pediatric patient, and parents or guardians. Child patient society Family (mother) Dentist & environment The pediatric treatment triangle illustrates basic relationship in pediatric dentistry 2 VARIABLES INFLUENCING CHILDREN’S DENTAL BEHAVIORS 1. Past dental history. a fearful or anxious child who anticipates an unpleasant visit is more likely to have such an experience than is a child who has a low level of fear or anxiety. 2. Maternal Anxiety. With few exceptions, most investigations indicate a significant correlation between maternal anxiety and a child’s cooperative behavior at the first dental visit. 3. Medical History. There is general agreement, however, that children who view medical experiences positively are more likely to be cooperative with the dentist. 4. Awareness of Dental Problem. CLASSIFYING CHILDREN’S COOPERATIVE BEHAVIOR Numerous systems have been developed for classifying the behavior of children in the dental environment. wright’s clinical classification places children in three categories:  Cooperative  Lacking in cooperative ability.  Potentially cooperative Another system, which has been used in behavioral science research, is referred to as the Frankl Behavioral Rating Scale. The scale divides observed behavior into four categories, ranging from definitely positive to definitely negative. Following is a description of the scale: Rating 1: Definitely Negative. Refusal of treatment, forceful crying, fearfulness, or any other overt evidence of extreme negativism. Rating 2: Negative. Reluctance to accept treatment, uncooperativeness, some evidence of negative attitude but not pronounced (sullen, withdrawn.). Rating 3: Positive. Acceptance of treatment; cautious behavior at times; willingness to comply with the dentist at times with reservation, but patient follows the dentist’s directions cooperatively. 3 Rating 4: Definitely Positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment. Parent-Child Separation Excluding the parent from the operating room can contribute toward development of positive behavior on the part of child. Over the years, Starkey has been one of the strongest advocates of separation of child from the parent during treatment and has suggested that the policy of requiring the parent to remain in the reception room could be justified for many of the following reason:  The parent often repeats orders, which creates an annoyance for both the dentist and the pediatric patient.  The parent injects orders, becoming a barrier to development of rapport between the dentist and the child.  The dentist is unable to use voice intonation in the presence of the parent because he or she may be offended.  The child divides attention between the parent and dentist.  The dentist divides attention between the parent and child. In addition most dentists probably are more relaxed and comfortable when the parent remains in the reception area. The dentists who exclude parents from the operatory must make exceptions. A parent can be major in supporting and communicating with a disabled child, often providing important information and interpretation. Another important exception relates to age. Very young children (those who have not reached the age of understanding and full verbal communication) have a close symbiotic relationship with parents; consequently, they usually are accompanied by them. BEHAVIOUR MANAGEMENT TECHNIQUES COMMUNICATIVE MANAGEMENT APROACHES (non-pharmacological techniques)  Behavior shaping.  Tell-Show-Do.  Reinforcement. 4   Modelling.  Voice control.  Hand-Over-Mouth. SEDATION AND GENERAL ANAESTHESIA (pharmacological techniques)  Relative analgesia.  Oral sedation.  Intravenous sedation.  General anesthesia. AIMS OF BEHAVIOUR MANAGEMENT To increase appropriate behaviour and decrease inappropriate behaviour in order to:  Foster a positive attitude to dentists, dental health and dental treatment;  Perform the necessary treatment. Development of the child Child development involves the study of all areas of human development from conception through young adulthood. It implies a sequential unfolding that may involve changes in size, shape, function, structure, or skill. The broad area of physical development involves changes that occur in children’s size, strength, motor coordination, functioning of body systems, and so forth. Thus the child’s total physical growth and efficiency from the moment of conception until adulthood is physical development. No two children, even in the same family, develop exactly along the same pattern, the child may have the definite chronologic age, but psychologically he may plus or minus several years of age. Another area that has received great attention from psychologists is the socialization of children. as with physical development, age-specific skills have been derived for social development; these take into account both interpersonal relationships and independent functioning skills. 5  Intellectual development is probably the area most comprehensively studied, beginning in the early 1900s with the work of Alfred Binet. The method that he employed quantified mental abilities in relation to chronologic age. It led to the concept of the IQ(intelligence quotient) Non- pharmacological techniques BEHAVIOR SHAPING It is that procedure which very slowly develops behavior by reinforcing successive approximations of the desired behavior until the desired behavior comes to be. When shaping behavior, the dental assistant or dentist is teaching a child how to behave. Young children are led through these procedures step by step. They have to be communicative and cooperative to absorb information that may be complex for them.  The dentist should explain the necessity for the procedure. A child who understands the reason is more likely to cooperate.  Reinforce appropriate behavior. Be as specific as possible, because specific reinforcement is more effective than a generalized approach.  Disregard minor inappropriate behavior. Ignored minor misbehavior tends to extinguish itself when it is not reinforced. Tell-Show-Do (TSD)technique More than four decades ago, Addelston formalized a technique that encompasses several concepts from learning theory. It was called the tell-show- do(TSD)technique. Since its introduction in 1959, it has remained a cornerstone of behavior management. It is a component of behavior shaping that should be routinely used by all members of the dental team who work with children. Dental assistants, dental hygienists, and dentists should demonstrate various instruments step by step before their application by telling, showing, and doing. when the dentist works intraorally, a pediatric patient should be shown as much of the procedure as possible. Only when the child has a view of the procedures being undertaken are successive approximations being performed properly. Although TSD is similar to behavior shaping the two differ. As well as demanding the reinforcement of cooperative behavior, behavior shaping also 6 includes the need to retrace steps if misbehavior occurs. For example, if a child is shown an instrument and looks away, the dentist must revert to the explanatory portion of the procedure. Behavior shaping requires that the “desired behavior” be observed along the way. If the dentist proceeds along the sequential steps and begins performing treatment when the desired behavior is not present, there is deviation from the learning model and a greater likelihood of increased misbehavior. Voice Control Throughout the dental literature, reference is made to voice control. it is difficult to describe this effective communicative technique using the written word. Sudden and firm commands are used to get the child’s attention or to stop the child form whatever is being done. Monotonous, soothing conversation is supposed to function like music set to a mood. In both cases what is heard is more important because the dentist is attempting to influence behavior directly, not through understanding. The theory of Cambers is that voice control is most effective when used in conjunction with other communication.’$ sudden command to “stop crying and pay attention” may be a necessary preliminary measure for future communication. AVERSIVE CONDITIONING The behavior modification method of aversive conditioning is also known as hand-over-over-mouth exercise. (HOME). its purpose is to gain the attention of a highly oppositional child so that communication can be established and cooperation obtained for a safe course of treatment. The technique fits the rules of learning theory: maladaptive acts (screaming, kicking) are linked to restraint (hand over mouth), and cooperative behavior is related to removal of the restriction and the use of positive reinforcement (praise). It is important to stress that aversive conditioning is not used routinely but as a method of last resort, 7 usually with children 3 to 6 years of age who have appropriate communicative abilities. For the very young, the immature, those with physical disabilities, or those who have mental or emotional disabilities, this behavioral approach is unacceptable. Aversive conditioning can be a safe and effective method of managing a child with an extremely difficult behavior problem. However, any departure from the accepted application of aversive conditioning may expose the dentist to liability. Those dentists or dental student who contemplate using it should consult detailed writings beforehand. Reinforcements Giving gifts to children has become a fact of commercial life in North America. there is general agreement in the dental office, for gift giving can serve as reward. If the gift has a dental significance (such as a toothbrush kit), so much the better. In these situations, the gift is also used as a reinforcement for dental health. Various trinkets in a toy chest should be used as tokens of affection for children not as bribes. Finn made the following distinction between rewards and bribes; “A bribe is promised to induce the behavior. A reward is recognition of good behavior after completion of the operation, without previously implied promise. The gift-giving practice can have spectacular results. Many children who seem tense during operative procedures suddenly perk up on completion and scurry for a gift. these gifts provide a pleasant reminder of the appointment. TREATMENT IMMOBILIZATION Partial or complete immobilization of the patient is sometimes a necessary and effective way to diagnose and deliver dental care to patients who need help controlling their extremities, such as infants or patients with certain neuromuscular disorders. Immobilization is also useful for managing combative, resistant patients, so that the patient, practitioner, and / or dental staff may be protected from injury while care is being provided. Treatment immobilization can be performed by the dentist, staff, or parent, with or without the aid of an immobilization device. The parents, guardian, or patient (if an adult) must be informed and must give consent, and consent must be documented, before immobilization is used. 8  These individuals should have a clear understanding of the type of immobilization to be used, the rationale, and the duration of use. in many cases this information should be included in the explanation of the overall management approach for the child during the initial examination and conference with the parents. The use of immobilization is indicated in the following situations:  A patient requires diagnosis or treatment and cannot cooperate because of lack of maturity.  A patient requires diagnosis or treatment and cannot cooperate because of metal or physical disabilities.  Patient requires diagnosis or treatment and does not cooperate after other behavior management techniques have failed.  The safety of the patient or practitioner would be at risk without the use of protective immobilization. Immobilization is contraindicated for a cooperative patient and patient who cannot be safely immobilized because of underlying medical or systemic conditions. immobilization should not be use as punishment and should be used solely for the convenience of the staff. The patient’s record should display an informed consent, the indications for use, the type of immobilization used, and the duration of application. Common mechanical aid for maintaining the mouth in an open position are: 1. Padded and wrapped tongue blades. 2. The Mouth Prop’. 3. Rubber bite blocks. 4. Body control is gained through a variety of methods and techniques. A. For children who are severely or very young, parents and dental assistants can assist in the control of movements during dental procedures. B. Papoose Board. C. Triangular sheet. 9