Management of Children's Behaviours 2018 PDF

NAHDA UNIVERSITY MANAGEMENT OF CHILDREN'S BEHAVIOURS Dr. AHMAD ABDEL HAMID ELHEENY 2018 DEFINITIONS Behaviour: Specific response of an organism to a specific stimulus (stimuli). Behaviour management: Means by which the dental health team effectively and efficiently performs trea...

NAHDA UNIVERSITY MANAGEMENT OF CHILDREN'S BEHAVIOURS Dr. AHMAD ABDEL HAMID ELHEENY 2018 DEFINITIONS Behaviour: Specific response of an organism to a specific stimulus (stimuli). Behaviour management: Means by which the dental health team effectively and efficiently performs treatment for a child and at the same, installs a positive dental attitude. GOALS OF BEHAVIOUR GUIDANCE 1. Establish effective communication with the child and the parent 2. Gain the confidence of both the child and the parent and the acceptance of dental treatment 3. Promote the child’s and parent’s positive attitude toward dental health care 4. Provide a relaxing and comfortable environment for the dental team to work in, while treating the Child (Deliver quality dental care) PAEDIATRIC TREATMENT TRIANGLE FACTORS AFFECTING CHILD BEHAVIOUR IN DENTAL OFFICE I. Factors Involving the Child 1. Adaptive Changes Seen in Children at Different Stages of Development New born- 2 years  Sensorimotor stage characterized by 1. Simple natural reflexes 2. Object permanence 3. Recreating satisfactory actions 4. Causes and effects 5. Experimentation  The language development of the infant is, at first, very slow  The mean expressive vocabulary of an 18-month-old is 10 words  Fear of strangers is almost a universal finding after 7 to 12 months of age  Another very common fear in this age group is fear of separation from the parents which starts around 6 months of age, peaks between 13 and 18 months Dr. AHMAD ABDEL HAMID ELHEENY Page 2 of 11   This the stage of trust versus mistrust  By the second year of life, Role model observation becomes important  The only way of communication is emotional  As long as child cries in despair way, dentist can accomplish his work 2 to 6 years  Preoperational stage  Egocentric (unable to understand that there is another points of view)  Unsophisticated in thinking and child still generalizes all entities  By age of 3, child has 1000 words or more reach up to 2000 words or more by age of 5  Anxiety decreases by age of 5 By age of 3 1. Child is semi independent and learns to do some things by himself 2. He likes to be praised 3. Me too stage By age of 4 1. How and why stage 2. More independent 3. Love show off 4. Respond well to verbal commands 5. Can be very cooperative 6. May be one of the most pleasant ages for dentist to practice By age of 5 and 6 1. Fear decline 2. Old enough to distinguish truth from falsehood (never lie to him) 3. Love praise 4. Proud of his accomplishments 5. Greater independence due to the expansion of outdoor activities By age of 6 to 12 1. Grows up cognitively. 2. By the age of 12 years, his mind and mental prowess have matured 3. Can apply logical reasoning 2. IQ of the Child Positive relationship exists between IQ and acceptance of dental treatment 3. Past Dental Experience Previous painful experience will be negatively reflected on the child’s behavior Dr. AHMAD ABDEL HAMID ELHEENY Page 3 of 11 4. Physical Condition of the Child 4.1. Chronic illness Has the spirit of “I can take too” Overindulgence 4.2. Nutrition Some vitamins deficiency will cause irritability, fatigue and restless and negatively affect the child’s behavior. 4.3. Physical and Mental Fatigue 4.4. School  Nursery child shows more socialization and has much experience than home child and mostly can adapt himself in new situations as dental clinic.  Have dental instructions in classroom.  May suffer from subjective fear from his peers. 5. Fear  Fear: It is a primary emotion of danger that acquired soon after birth.  Anxiety: It is a fear but without the known reasons (fear of the unknown). Types of Fear  Objective Fear: They are produced by direct physical stimulation.  Subjective Fear: These are based on the feelings and attitudes that have been suggested to the child by others about dentistry without the child having had the experience personally. II. Factors Involving the Parents 1. Family Influence 1.1. Family structure Children do best when raised by two caring, cooperative parents with adequate social and financial resources providing a secure, supportive, and nurturing environment. 1.2. Attachment  The bonding of an infant with a parent0  Unsecure attachment makes child feeling threaten in new situations, so child shows fear, reluctant and defiant. Dr. AHMAD ABDEL HAMID ELHEENY Page 4 of 11 1.3. Family Functioning Models Children from dysfunctional families have increased risk for dental anxiety and poor cooperation. 1.4. Genetic Contribution 2. Parent-Child Relationship Dr. AHMAD ABDEL HAMID ELHEENY Page 5 of 11 3. Maternal Anxiety  There is significant correlation between maternal anxiety and a child's cooperative behavior at the first dental visit.  High anxiety on the part of parents tends to affect their children's behavior negatively. 4. Parental Attitude toward Dentistry Parents with positive dental attitude will develop the same in the child. Parent-Child Separation 1. Parent often repeats orders, which creates an annoyance for both the dentist and the paediatric patient. 2. Parent injects orders, becoming a barrier to development of rapport. between the dentist and the child. 3. Child divides attention between the parent and dentist. 4. Dentist divides attention between the parent and child. 5. Dentist is unable to use voice intonation in the presence of the parent because he or she may be offended. 6. Dentists probably are more relaxed and comfortable. III. Factors Involving the Dentist 1. Appearance of Dental Office 2. Personality of Dentist Dental team should be Confident Kind Friendly Never lose his temper Do not talk in a loud voice or shake hands vigorously Call the child with his nick name 3. Time and Length of Appointment. 4. Skill and Speed of Dentist. 5. Avoiding the use of Fear Promoting Words. CLASSIFICATION OF CHILD BEHAVIOUR I. Frankel’s Behaviour Rating Scale (1962) Rating No. 1(Definitely negative) – Refuses treatment – Immature, uncontrollable – Defiant behaviour – Crying forcefully Dr. AHMAD ABDEL HAMID ELHEENY Page 6 of 11 Rating No. 2 (Negative) – Reluctance to accept treatment – Uncooperativeness – Immature, timid Rating No. 3 (Positive) – Acceptance of treatment with cautious behaviour at times – Willingness to comply with the dentist, at times with reservation – Patient follows the dentist's directions cooperatively Rating No. 4 (Definitely positive) – Good rapport with the dentist – Interest in the dental procedures – Laughter and enjoyment II. Wright’s Classification of Behaviour (1975) 1. Cooperative 2. Lacking in cooperative ability 3. Potentially Cooperative Behaviour Uncontrolled 1. Seen in 3-6 years If it occurs in older children, there may (Incorrigible) deep rooted reasons 2. Tantrum may begin in the reception area or even before. 3. Tears, loud crying, physical lashing out and flailing of the hands and legs—all suggestive of a state of acute anxiety or fear Defiant 1. All ages (stubborn” or 2. I don’t want to “spoilt) 3. Once won over, these children frequently become highly cooperative Timid 1. May shield behind the parent 2. Not cry hysterically 3. If managed incorrectly, their behaviour can be uncontrolled 4. Needs to gain self-confidence Tense 1. Accept treatment, but are extremely tense cooperative 2. Tremor may be heard, when they speak Whining 1. They do not prevent treatment, but whine throughout the procedure 2. Cry is controlled, constant and not loud 3. Seldom are there tears Dr. AHMAD ABDEL HAMID ELHEENY Page 7 of 11 BEHAVIOUR GUIDANCE TECHNIQUES a. Preappointment behaviour modification b. Communication c. Behavioural shaping 1- Tell-show-do technique 2- Desensitization 3- Modelling 4- Contingency d. Other methods 1- Distraction/audioanalgesia 2- Voice control 3- Aversive conditioning techniques—HOME 4- Retraining 5- Restraint 1. Preappointment Behaviour Modification It is anything that is said or done to positively influence the child's behaviour before the child enters a dental operatory Types: a. Positive reappointment imagery b. Direct observation Audiovisual modelling Live models c. Preappointment mailing 2. Effective Communications The hallmark of a successful dentist in managing child dental patient is his ability to communicate with them and win their confidence The age of the child also dictates the level and amount of information that can be included in the communication Communication may be; Verbal or Non verbal 2.1. Establishing communication  Children are often shy and reluctant to talk when they are first exposed to a new experience and to new people. When they have gained confidence and are comfortable in the unfamiliar environment, they will usually speak more freely.  During the first dental visit they may speak more readily to a dental assistant. This enables the dentist to listen and make an evaluation of the comprehension and emotional maturity of the child. Dr. AHMAD ABDEL HAMID ELHEENY Page 8 of 11   Generally, verbal communication with younger children is best initiated with complimentary comments, followed by questions that elicit an answer other than yes or no 2.2. Message Clarity It is important to be careful in selecting words and phrases used to indoctrinate the new paediatric dental patient.  For paediatric dentists, euphemisms or word substitutes are like a second language  Commands should be given in a positive manner 2.3. Multisensory Communication  Body contact (e.g. dentist's simple act of placing a hand on a child's shoulder while sitting on the stool conveys a feeling of warmth and friendship)  Sitting and speaking at eye level allows for friendlier and less authoritative communications 2.4. Confident communication 2.5. Active Listening Listening to the spoken words may be more important in dealing with the older child than it is in dealing with the younger child 2.6. Problem Ownership If a child reacts negatively, the problem belongs to the dentist. Often, the first attempt to resolve such a problem involves giving orders to the child, such as “You must stop crying!” and “You must sit still!” These messages tell children that they have no control over the situation. CLINICAL STRATEGIES FOR BEHAVIOUR MANAGEMENT 1. Behaviours Shaping Definition It is that procedure which very slowly develops behaviour by reinforcing successive approximations of the desired behaviour until the desired behaviour comes to be. It is sometimes called as ‘Stimulus response theory“ 1.1. Tell-Show-Do (TSD) Tell 1. State the general goal or task to the child at the outset. 2. Explain the necessity for the procedure. A child who understands the reason is more likely to cooperate. Dr. AHMAD ABDEL HAMID ELHEENY Page 9 of 11  3. Divide the explanation for the procedure. Children cannot always grasp the overall procedure with a single explanation; consequently, they have to be led through the procedure slowly. 4. Give all explanations at a child's level of understanding. Use euphemisms appropriately. Show  Demonstrating on an inanimate object to be sure that understanding is complete. Do  Perform the previewed operation 1.2. Desensitization Technique involves three stages 1. Training the patient to relax 2. Constructing a hierarchy of fear producing stimuli related to the patient’s principal fear 3. Introducing each stimulus in the hierarchy in turn to the relaxed patient, starting with the stimulus that causes least fear and progressing to the next only when the patient no longer fear that stimulus 1.3. Modelling 1.4. Contingency Management  The presentation or withdrawal of reinforces to modify a child’s behaviour  Positive reinforces—whose contingent presentation increases the frequency of behaviour.  Negative reinforces—is one whose contingent withdrawal increases the frequency of a behaviour  Reinforces can be material, social or activity  Reinforce appropriate behaviour and disregard minor inappropriate behaviour. Ignored minor misbehaviour tends to extinguish itself when it is not reinforced 2. Distraction Distraction is the technique of diverting the patient’s attention from what may be perceived as an unpleasant procedure. Thus it helps to decrease the perception of unpleasantness and avert negative or avoidance behaviour. 3. Retraining  It is required for children displaying considerable apprehension or negative behavior.  The demonstrated behavior may be the result of previous dental visit or the effect of improper parental or peer orientation.  During retraining, the objective is to build new series of associations in the child's mind Dr. AHMAD ABDEL HAMID ELHEENY Page 10 of 11   The dental team has to demonstrate a "difference" and create new stimulus which is pleasant and replaces the old 4. Aversive conditioning (Hand-Over-Mouth Exercise) 1. Place the hand over the child’s mouth 2. Bring your face close to the child and talk directly into the ear 3. Quietly, tell the child to stop screaming and listen, and then you will remove hand 4. Explain that you “only want to talk and look at your teeth.” 5. Repeat the instructions after a few seconds, adding: “Are you ready for me to remove my hand?” Indication of HOME technique 1. For normal children who are momentarily hysterical, belligerent or defiant. 2. Used for children with sufficient maturity to understand simple verbal commands. Contraindication of HOME technique  Immature, frightened or the child with a serious physical, mental or emotional handicap. Purpose  Gain the child’s attention and to stop his verbal outburst so that communication can be established. 5. Restraint (Protective stabilization) For the Body  Papoose board.  Triangular sheet.  Pedi wrap  Beanbag dental chair insert.  Extra assistant For the Teeth  Padded and wrapped tongue blades  Mouth prop or bite lock For the Head  Head positioner  Extra assistant For the Extremities  Posey straps  Towel and tape  Forearm body support  Extra assistant Dr. AHMAD ABDEL HAMID ELHEENY Page 11 of 11