Behaviour Management in Children PDF

Management of Children's Behaviours Assistant Prof. AHMED ABDEL Hamid ELHEENY  CONTENTS 1. Definitions 2. Goals of Behaviour Guidance 3. Factors Influencing Child Behavior in Dental Clinic 4. Classifications of Children’s Behavior 5. Behavior Management St...

Management of Children's Behaviours Assistant Prof. AHMED ABDEL Hamid ELHEENY  CONTENTS 1. Definitions 2. Goals of Behaviour Guidance 3. Factors Influencing Child Behavior in Dental Clinic 4. Classifications of Children’s Behavior 5. Behavior Management Strategies 1. Emotional Development Age Stage Virtue Failure 1 0-18m Trust vs. mistrust Hope Fear or suspicious 2 18m-3y Autonomy vs. doubt Will shame 3 3-6y Initiative vs. guilt Purpose Inadequacy 4 7-11y Industry vs. inferiority Competence Inferiority 2. Cognitive Development 1. Sensimotor 4. Formal Piaget 2. operation theory Preoperational 3. Concrete operation Stage 1 Stage 2 Stage 3 Stage 4 Symbolism to describe objects Egocentric Child thought Use of 5 senses process declines become similar Still use 5 senses to that of an adult Object Animism Animism permanence declines Understand Limited concepts like reasoning Understand health, disease, concept of and preventive Egocentric Concept of conservation in treatment conservation concrete way Definitions Behavior: Specific response of an organism to a specific stimulus (stimuli) Behavior guidance : 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) Principles of Behavior Management Technique 1. Anticipation 2. Diversion 3. Substitution 4. Restriction The paediatric treatment triangle I. Factors Involving the Child 1. Adaptive Changes Seen in Children at Different Stages of Development New born- 2 years Sensorimotor stage characterized by a) Simple natural reflexes b) Object permanence c) Recreating satisfactory actions d) Causes and effects e) 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 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 7 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 out door activities By age of 7 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 4. Physical Condition of the Child 4.a. Chronic illness Has the spirit of “I can take too” Overindulgence 4.b. Nutrition Some vitamins deficiency will cause irritability, fatigue and restless and negatively affect the child’s behavior 4.c. Physical and Mental Fatigue 4.d. School Nursery child shows more socialization and has much experience than home child and mostly can adapt himself in new situations as dental clinic Has 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 If the parent displays fear the child is fearful A mother who fears going to the dentist may transmit this unconsciously to her child who is observing her. A fearful child matures to become a fearful parent and a fearful parent produces a fearful child leading to a viscous cycle. II. Factors Involving the  1. Family Influence 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 Attachment The bonding of an infant with a parent Unsecure attachment makes child feeling threaten in new situations, so child shows fear, reluctant and defiant Family Functioning Children from dysfunctional families have increased Models risk for dental anxiety and poor cooperation Genetic Contribution Family functioning typology and child security outcomes Main features Boundaries Cohesive family Warm Discrete but Close flexible Harmonious family Autonomy relationships of family members is respected Enmeshed or High levels of Discordant and/or chaotic family conflict and hostility weak Disengaged or Emotionally cold Rigid separate family relationships High levels of adversity 2. Parent-Child Relationship 1. Over-protective/over-anxious parents 2. Over indulgence 3. Over authority 4. Under affection 5. Rejection 6. Identification Over- Previous miscarriage Lack of courage Timid protective Delay in conception Can’t take decision Shy Only child Dependant Easily cry Death of siblings Fearful Youngest child Over Parents give the child Spoiled Aggressive indulgence whatever the child asks Selfish Defiant Battle with those not Resistant do his wishes Display Temper tantrum Over Parents demands Submissive Tense authority from child Obey commands Restless responsibilities over his age Under Little time for children Feeling insecure Timid affection Presence of several May develop bad Shy siblings habits as thumb Easily cry low y socioeconomic sucking Fearful level Rejection Parents have emotional Spoiled Aggressive problems Selfish Defiant May lie Resistant Hyperactive Display Temper tantrum Identification Some parents try to Submissive Tense relive their own lives Obey commands Restless in those of their children Easily cry 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 Parental presence/absence Objectives: for parents: — participate in examinations and treatment; — offer physical and psychological support; and — observe the reality of their child’s treatment. objectives of for practitioners: — gain the patient’s attention and improve compliance; — avert negative or avoidance behaviors; — establish appropriate dentist-child roles; — enhance effective communication among the dentist, child, and parent; — minimize anxiety and achieve a positive dental experience; — facilitate rapid informed consent for changes in treatment or behavior guidance  Parent often repeats orders, which creates an annoyance for both the dentist and the paediatric patient Parent injects orders, becoming a barrier to development of rapport between the dentist and the child Child divides attention between the parent and dentist Dentist divides attention between the parent and child Dentist is unable to use voice intonation in the presence of the parent because he or she may be offended 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 loose 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 Frankel’s Behavior Rating Scale (1962) A. Rating No. 1 B. Rating No. 2 Definitely negative --* Negative - – Refuses treatment – Reluctance to accept – Immature, uncontrollable treatment – Defiant behavior – uncooperativeness – Crying forcefully – Immature, timid and whining C. Rating No. 3 D. Rating No. 4 Positive + Definitely positive ++ – Acceptance of treatment – Good rapport with the with cautious behavior at Dentist times – Interest in the dental – Willingness to comply with procedures the dentist, at times with – Laughter and enjoyment reservation – Patient follows the dentist's directions cooperatively * Wright (1975)12 added symbolic modifications to the Frankel’s rating scale Wright’s Classification of Behavior (1975) 1. Cooperative 2. Lacking in cooperative ability 3. Potentially Cooperative Behavior 1. Uncontrolled behavior 2. Defiant behavior 3. Timid behavior 4. Tense cooperative behavior 5. Whining behavior Uncontrolled Seen in 3-6 years If it occurs in older children, there may (Incorrigible) deep rooted reasons Tantrum may begin in the reception area or even before. Tears, loud crying, physical lashing out and flailing of the hands and legs—all suggestive of a state of acute anxiety or fear Defiant All ages (stubborn” or I don’t want to “spoilt) Once won over, these children frequently become highly cooperative Timid May shield behind the parent Not cry hysterically If managed incorrectly, their behaviour can be uncontrolled Needs to gain self-confidence Tense Accept treatment, but are extremely tense cooperative Tremor may be heard, when they speak Whining They do not prevent treatment, but whine throughout the procedure Cry is controlled, constant and not loud Seldom are there tears Behavior Guidance Techniques a. Preappointment behavior modification b. Communication c. Behavioral 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 BEHAVIOR MODIFICATION It is anything that is said or done to positively influence the child's behavior before the child enters a dental operatory Pre-visit mailing Positive pre-visit imagery Description Patients preview positive photographs or images of dentistry and dental treatment before the dental appointment Objectives — provide children and parents with visual information on what to expect during the dental visit; and — provide children with context to be able to ask providers relevant questions before dental procedures commence. Direct observation Description Patients are shown a video or are permitted to directly observe a young cooperative patient undergoing dental treatment — Audiovisual modelling — Live models Objectives — Familiarize the patient with the dental setting and specific steps involved in a dental procedure — Provide an opportunity for the patient and parent to ask questions about the dental procedure in a safe environment 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 Non verbal 2.a. 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.  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.b. Message Clarity It is important to be careful in selecting words and phrases used to indoctrinate the new pediatric dental patient  For paediatric dentists, euphemisms or word substitutes are like a second language Commands should be given in a positive manner 2.c. 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.d. Confident communication 2.e. 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.f. 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. An alternative is to send “I” messages which is effective communication “I can’t fix your teeth if your mouth is not open wide” Non-Pharmacologic Clinical Strategies 1. BEHAVIOR SHAPING 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. It is sometimes called as ‘Stimulus response theory“ Tell-Show-Do Tell Show Do Explain the general Demonstrating Perform the goals on an previewed Explain the necessity inanimate operation for the procedure object to be Explains in simple sure that words understanding is complete Explain slowly and with as much repetition as necessary Ask-tell-ask Description — Inquiring about the patient’s visit and feelings toward or about any planned procedures (ask) — Explaining the procedures through demonstrations and non-threatening language appropriate to the cognitive level of the patient (tell) — Again inquiring if the patient understands and how she feels about the impending treatment (ask) If the patient continues to have concerns, the dentist can address them, assess the situation, and modify the procedures or behavior guidance techniques if necessary Objectives — Assess anxiety that may lead to noncompliant behavior during treatment — Teach the patient about the procedures and their implementation — Confirm the patient is comfortable with the treatment before proceeding 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.c. Modelling Discussed before in preappointment behavior modification 1.d. Contingency management The presentation or withdrawal of reinforces to modify a child’s behavior Positive reinforces—whose contingent presentation increases the frequency of a behavior Negative reinforces—is one whose contingent withdrawal increases the frequency of a behavior Reinforces can be material, social or activity Reinforce appropriate behavior and disregard minor inappropriate behavior. Ignored minor misbehaviour tends to extinguish itself when it is not reinforced 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 behavior — decrease the perception of unpleasantness; and — avert negative or avoidance behavior 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 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 For normal children who are momentarily hysterical, belligerent or defiant. 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 For the Head Papoose board. Head positioner Triangular sheet. Extra assistant Pedi wrap Beanbag dental chair For the Extremities insert. Posey straps Extra assistant Towel and tape Forearm body support Extra assistant For the Teeth Padded and wrapped tongue blades Mouth prop or bite lock  For the body papoose board  Pedi wrap Beanbag Triangular sheet Extra assistant  For the Head Dentist's hands, forearm, and Head positioner body.  For the Extremities Posey straps Towel and tape on forearm.  For the teeth Padded and wrapped Mouth prop or bite lock tongue blades Pharmacological Behavior Management  Differences between adults and children CNS CVS RESPIRATORY At birth brain weight is Autonomic control AVR 10% of total body (Autonomic tone) FRC weight At birth 25% of neural Heart rate and Children are more cells present myocardial contraction liable for upper which reach adult respiratory air way development at 8y block Myelination completed 6m 120±20 Tonsillar tissues at 3yr 5yr 90±10 occupy ˃50% of 12yr 70±17 pharyngeal space  Levels of sedation Intended Responsiveness Airway Spontaneous CVS level ventilation Minimal Normal to Unaffected Unaffected Unaffected verbal stimulation Moderate Purposeful to No Adequate Maintained verbal and intervention without tactile required intervention stimulation Deep Purposeful after May require May be Maintained repeated or assistance impaired without painful intervention stimulation General Cannot arouse intervention Frequently Could be anesthesia even with required inadequate impired painful stimulation  Goals of sedation 1) to guard the patient’s safety and welfare, 2) to minimize physical discomfort and pain, 3) to control anxiety, minimize psychological trauma, and maximize the potential for amnesia, 4) to control behaviour and/or movement so as to allow the safe completion of the procedure, 5) to return the patient to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible  AAPD GUIDELINES 1. INFORMED CONSENT 2. CHILD HEALTH EVALUATION Age and weight Medical history Physical examination Recording vital signs Good candidates for sedation are ASA I&II ASA II ASA III No functional limitations Some functional limitation Well-controlled disease of one Controlled disease of more than body system one body system or one major Controlled hypertension or system diabetes without systemic No immediate danger of death effects Controlled congestive heart Cigarette smoking without failure (CHF), stable angina, old chronic obstructive pulmonary heart attack, poorly controlled disease (COPD) hypertension chronic renal Mild obesity failure; bronchospastic disease Pregnancy with intermittent symptoms 3. Airway Assessment: Mallampati Class 1: soft palate, fauces, uvula, pillars Class 2: soft palate, fauces, portion of uvula Class 3: soft palate, base of uvula Class 4: hard palate only 4. INSTRUCTION BEFORE SEDATION 5. MONITORING AND EQUIPMENTS  Benzodiazepines (BZ) Diazepam Midazolam Action Anxyolysis Action The same Amnesia Anticonvulsant Hypnosis Muscle relaxant Side effects Apnea Side effects Apnea Ataxia Ataxia Prolonged sedation* Onset of action 15-30 minutes Onset of action 15-30 minutes Dosage 0.2-0.5mg/kg Dosage 0.25-1mg/kg (10gm) Half life time 21-37 hours Half life time 1-4 hours *Due to rebound effect metabolize into 2 compounds desmethyldiazepam and oxazepam and it is highly lipid soluble. **Midazolam is 2 to 5 times more potent than valium but cause hypoxia and more amnesia more than that of valium  Antihistamines Action Sedative Antihistaminic Antiemetic Antimuscarinic* Antipsychotics** (Promethazine) Side effects Drowsiness Ataxia Paradoxical reaction Onset of Peak Half life time Dosage action Hydroxizine 20 minutes 2 hours 3 hours 0.5-1mg/kg (Atarax, Vistaril) Promethazine 20 minutes 2-3 hours 7-14 hours 0.5-1mg/kg (Phenergan) Diphenhydramine 1 hours 2-8 hours 1-1.5 mg/kg (Benadryl)  Opioid Action Sedative Analgesic Decrease cough reflex Not affecting memory or awareness Side effects Apnea CNS excitation Delayed gastric empting, cause constipation Urinary retention Onset of Peak Half life time Dosage action Fentanyl 7-15 minutes 1-2 hours 0.002-0.004 (Sublimaze) mg/kg* Meperidine 15-40 hours 1-2.2mg/kg (Demerol) Usually given parental not oral because its bioavilability reduced significantly by the first pass metabolism in liver *0.1 mg fentanyl equal 10 mg morphine Mepridine C/I with patients have liver disease because 90% of drug metabolized via first pass metabolism  Chloral hydrate Action Sedative Hypnotic Side effects Nausea and vomiting Irritant to skin and mucous membrane Excitement and irritability before reaching sedation level Large doses cause arrhythmias Onset of Peak Elimination Dosage action Half life time Chloral hydrate 30-60 4-8 hours 8-11 hours 25 mg/kg minutes  Reversal agents Drug Proprietary Route Action Dose Flumazenil Romazicon IM BZ reversal 0.01mg/kg IV First dose 0.2mg Naloxone Narcan IM Narcotic