Child psychology and behaviour management lec.pdf

Dr. Nadin Elgandouz BDS.MSc RWTH AACHEN/GERMANY  Psychology --- science dealing with human nature, function and phenomenon of his soul in the main. Its the study of human mind & its functions  Child psychology --- science that deals with the mental power or an interaction between the c...

Dr. Nadin Elgandouz BDS.MSc RWTH AACHEN/GERMANY  Psychology --- science dealing with human nature, function and phenomenon of his soul in the main. Its the study of human mind & its functions  Child psychology --- science that deals with the mental power or an interaction between the conscious and subconscious element in a child  Emotion --- a feeling or mood manifesting into motor and glandular activity.  Behaviour --- is any change observed in the functioning of the organism.  To understand the child & know his problem  To deliver treatment effectively  To establish effective communication with child and parents  To gain confidence of child and parents  To teach and motivate them about importance of primary and preventive care  To plan out effective treatment  To provide comfortable and satisfactory treatment  What is child development and behaviour?  Child development describes the changes children experience as they grow older. As children grow physically, they also develop in their knowledge, skills, and behaviour. Parents and other adults, such as grandparents and child care providers, play important roles in children's development.  Age 6-8 months  Age 9-12 months  Age 1-3 years  Age 3 years  Age 4-5 years  Age 6-8 years  Age 8-12 years  Age 10-19 years ( adolescence)  Pays increasing attention to speech  Responds to simple verbal requests  Responds to “no”  Explores objects in many different ways (shaking, banging, throwing, dropping)  Shy or anxious with strangers  Easily distracted and frustrated  Attention span 1-5 min  Favorite word is NOOOO ! Independent Less egocentric Eager to please Imitate adult behaviour Enjoy stories and continue to ask why Attention span 4-8 min  Independent and controlled  Self confident  Respond well to verbal direction  Fluent speech  Less combative and accept authority more  By 6, kids are moving away from the security of the family and being independent  This transition may cause anxiety and temper tantrums  By8 children are part of larger social groups and strongly influenced by them, they learn to hide their feelings and adopt a cool attitude 1-3 years 3 years 4-5 years 6-8 years 8-12 years *Difficult of Use of praise Can be co- Ideal time to Respond well communication Telling stories operative and help childe to to puts the child help to respond well be able to go explanations in * capture child to please/ alone from Engage in pre-co- attention and thank you waiting room tooth brush operative to distract Allowing to the clinic and flossing stage him from decision make New fears on their own Should be unpleasant choices may develop accompanied aspects in Comments even if the with patient dental clinic about child has *Allowed to clothing can been a prior touch and be effected patient handle to establish objects to good understand communicatio their meaning n  1-3 y: be consistent, praise, clear and simple commands, give simple choices and communicate trough parents  3-6 y: encourage, praise, give simple choices, answer their questions and communicate through/ with parents  6-12 y: encourage and support, sit clear limits, be clear about expectation and communicate with parents  Parenting styles, the environment, interactions with peers, cultural norms and values, as well as inherited traits, all contribute to a child's behavioural patterns  Fear and dental anxiety have great impact on children behaviour  Itis primary emotion to survive against danger  Objective fear  Subjected fear 1. Fear of the unknown 2. Previous bad experience 3. Fear if invasion of personal space 4. Acquired fear 5. Fear of pain 6. Fear of noise 7. Fear induced by emotional state of dental team  This fear is acquired as a natural course of growing fears  Fear of the unknown is real and valid. Children may express fear or anxiety about an upcoming dental appointment because they don’t know what to expect.  Due to lack of trust in the dentist and lack of control over a traumatic event.  Its important to determine behaviour management technique that help the patient regain trust  In regards to specific procedures, the dental injection was the most feared procedure, followed by “drilling” and “tooth scaling.”  children’s dental anxiety and diminishes with increasing age.13  Not every child has learned that it is save and correct to allow a clinical professional as close to them as this  Respect their personal space  Hearing stories about fear of dental clinic from siblings or rivals and friends  It has reported that fearful dental patient come from families with unpleasant dental experience  Itis a Real pain fear and must be approached carefully with caution  Threshold of pain differ from one child to another  Noises of dental equipment may induce child anxiety  Inform young child of the possible noises and reassure him at all time  Emotional state of dental team can have an impact on child  Communication, professionalism, friendliness, respect and patience are required when dealing with pediatric patients  Definition: The means by which the dental health team effectively and efficiently performs treatment for a child & in the same time instills a positive dental attitude.  BEHAVIOUR MODIFICATION:- is defined as the attempt to alter human behavioral emotion in a beneficial way.  To establish an effective communication with child and parent.  To gain confidence of child and parent.  To teach child and parent the positive aspects of preventive dental care.  To provide a relaxing and comfortable environment for the dental team to work in while treating the child.  Divided into four categories 1. definitively negative {- -}  Features: Refusal of treatment  Crying forcefully  Extreme negativism 2. negative {–}  difficult to accept treatment  Un co-operative  3. positive {+}  :Acceptances of treatment.  Willingness to follow dentists instruction.  May be hesitant too.  4. Definitely positive{ + +}  Good rapport with dentist.  Will enjoy the procedure.  ADVANTAGES:  Prepares team to face patient.  Is functional scale and easy to learn. 1. COOPERATIVE(POSITIVE BEHAVIOUR) 2. UN-COOPERATIVE(NEGATIVE BEHAVIOUR)  CO OPERATIVE :  a) COOPERATIVE BEHAVIOUR  b) LACKING COOPERATIVE ABILITY: usually seen in young child,(0-3 yrs.), disabled child, physical and mental handicap.  c) POTENTIALLY COOPERATIVE: has the potential to cooperate, but because of the inherent fears (subjective/objective) does not cooperate.  UN-COOPERATIVE  a) UNCONTROLLED/HYSTERICAL:  usually seen in  preschool children at their first dental visit  temper tantrums i.e physical lashing out of legs & arms, loud crying and refuses to cooperate with the dentist  b) DEFIANT/OBSTINATE BEHAVIOUR:  can be seen in any age group  usually in stubborn children  these children can be made cooperative  c) TENSE COOPERATIVE:  in the borderline between positive and negative BEHAVIOUR  does not resist the treatment but is tensed at mind  Suggestive and imitative fear  d) TIMID BEHAVIOUR/TIMID:  seen in over protective child at first visit  is shy but cooperative  e) WHINING TYPE: complaining type of BEHAVIOUR allows for treatment but complaints through out the procedure  f) STOIC BEHAVIOUR: seen in physically abused children. they are cooperative & passively accept all treatment without any facial expressions.   CLASSIFICATION 1.COMMUNICATION 2.BEHAVIOUR SHAPING 3.BEHAVIOUR MANAGEMENT Behaviour shaping  a.) DESENSITIZATION  b.) MODELLING  c.) CONTINGENCY MANAGEMENT  Behaviour managements  1.) AUDIO ANALGESIA  2.) HYPNOSIS  3.) COPING  4.) RELAXATION  5.) AVERSIVE CONDITIONING  6.) FLOODING  7.) RETRAINING  1. Communication  2. Behaviour modification(shaping)  Pre- appointment behavior modification  3. Behaviour management  Communication Universally applicable tool  It is the basis for establishing a strong relationship with the child patient.  Helps in completion of dental procedures and development of a positive attitude in children.  Should be initiated at the time of entry of the child into dental office and continued through the entire treatment time.  TYPES:  Verbal- by speech  Non-verbal- in the form of body language, eye contact, smile, expressions,  Touching, patting etc  Both verbal and non-verbal  Communication Words chosen should be pleasant and expressing concern  Patient should be addressed by his name  Use of euphemisms -euphemisms is substitute words which can be used in presence of children. Eg: raincoat for rubber dam.  BEHAVIOUR MODIFICATION IS DEFINED AS ” THE ATTEMPT TO ALTER HUMAN BEHAVIOR & EMOTION IN A BENEFICIAL MANNER ACCORDING TO THE LAWS OF MODERN LEARNING THEORY” Based on stimulus-response theory:  It is a step by step technique to make the child involved in dental therapy  Itinvolves three techniques:  DESENSITIZATION  MODELLING  CONTINGENCY MANAGEMENT DESENSITIZATION  The concept comes from “systemic desensitization” used to reduce anxiety in patients by behavior therapists.  Patient learns to replace anxiety by relaxation  The method employed is called TELL-SHOW- DO  Introduced by (Addelston)  Involves telling, showing of stimuli in increasing order of fear, followed by doing the procedures.  Language chosen should be simple  The situation is presented to the child slowly and repeatedly  Indications:  Initialvisit  Subsequent visits for every new interaction of the child  Apprehensive child due to previous information.  Effective in children above 3 yrs of age  Begins from initial entry till completion of the procedure  The basic procedure involves allowing the patient to observe one or more individuals who demonstrate appropriate behaviors in a particular situation  The model may be real or symbolic(posters)  Was introduced by BANDURA  Steps-  Gain attention of the patient  Desired behavior is modeled  Physical guidance may be needed  Reinforcement of guided behavior  Reinforcements for appropriate behaviors without modelling  Itis effective when :  Observer is aroused  Associated with positive consequences  It is a method of modifying the behavior of children by presentation or withdrawal of reinforcers  Reinforcers by definition increase the frequency of a behavior  Types of reinforcers:  Positive: presentation of which increases behavior ( reward good behaviour )  Negative: withdrawal of which increases behavior  Can also be classified as  Social reinforcers-praise, facial expressions, physical contact  Material reinforcers- toys, games. Sweets should not be given.  Activity reinforcers- seeing a movie, watching tv,outdoor games,etc  It involves preparing the child as well as the parents for the forthcoming dental visit.  This can be done by:  Messages in the form of letters or s  by showing videotapes, audiovisual aids and live models.  1. Audio-analgesia Also called as WHITE NOISE  Involves providing a sound stimulus of such intensity that the patient finds it difficult to attend to anything else.  2. Hypnosis  Also called as “suggestion therapy”  Technique of producing altered state of consciousness without the use of pharmacological agents.  Very rarely used in dentistry. 3. coping  Children respond to stressful situations by coping.  It includes an individual’s internal and emotional processes and his external behavioral responses.  The way the patient copes with his fears determines the type of patient he is.  Mechanisms:  By thinking of something else- “Distraction”  Verbalizing fears to others  Preferring to be with others, say, mother- this is called “employing affiliative behavior”  “Mental rehearsal”- going over in one’s mind in advance the sequence of anticipated events and reappraising the threats involved.  4. relaxation  It involves a series of basic exercises which the patient practices at home and may require several weeks to months to learn.  Therefore seldom used by clinicians.  5. Aversive conditioning  It is the extension of overall behaviour guidance designed to facilitate the goals of communication, cooperation & delivery of quality oral health care in difficult children.  It includes three practices: 1. Voice control 2. Hand-over-mouth exercise (HOME) 3. Physical restraint/Treatment immobilization  Voice control is a controlled alteration of voice, volume, tone, or pace to influence & direct the patients behaviour.  Parents unfamiliar with this technique may benefit from a prior explanation to prevent misunderstanding  OBJECTIVES:  To gain patient’s attention & compliance.  To avert negative or avoidance behaviour.  To establish authority  2. Hand-over-mouth exercise (HOME)  OBJECTIVES:  To redirect child's attention enabling communication  To extinguish excessive avoidance behavior  To reduce the need for sedation or G.A.  INDICATIONS:  For uncooperative child  A healthy child who is able to understand verbal commands & cooperate , but exhibits negative behaviour  CONTRAINDICATIONS:  Child under 3 yrs of age  Special child (physically, emotionally & mentally compromised)  Child with airway obstruction or mouth breather.  MODIFICATIONS:  HOM with airway unrestricted  HOM with airway restricted (HOMAR)  Towel held over nose & mouth  Dry towel held over nose & mouth  Wet towel held over nose & mouth  It is the direct application of physical force to a patient with or without the patient’s permission to restrict his or her freedom of movement.  It may be:  Active: Performed with restraining device  Passive: Performed without restraining device  OBJECTIVES:  To eliminate unwanted movement.  To protect patient, staff or dentist from injury  To facilitate quality dental treatment.  INDICATIONS:  A patient who requires immediate diagnosis treatment & can’t cooperate  When the safety is at risk  Child who is becoming tired from long appointments  A sedated pt who requires limited stabilization  Stubborn child  Physical restraint  PRECAUTIONS:  Tightness & duration of the stabilization must be monitored  The stabilization must not restrict circulation  Stabilization should be terminated as soon as possible in a patient who is experiencing severe stress  6. Implosion Therapy( flooding )  Child patient is flooded with so many stimuli that he has no other option than to face it, until the negative behavior disappears.  It may include HOME, voice control, physical restraints.  7. Retraining  employed in case of children presenting negative behavior, with bad experience in previous dental visits, or improper peer or parental orientation.  The child presents such behavior due to STIMULUS GENERALISATION, where similarities in stimuli generate similar responses.  In retraining, we make the child DISCRIMINATE between old and new stimuli,  The older response gradually diminishes - this is known as RESPONSE EXTINCTION.  THEUSE OF PHARMACOLOGICAL MEANS HAS MADE DENTAL TREATMENT ACCEPTABLE TO LARGE EXTENT.THESE PROCEDURES CAN BE CARRIED OUT IN THE NORMAL CIRCUMSTANCES WITH THE HELP OF BEHAVIOUR SHAPING TECHNIQUES. CLASSIFICATION:-  CONCIOUS SEDATION  DEEP SEDATION  GENERAL ANAESTHESIA  [SEDATION]  A minimally depressed level of consciousness, that retains the patient’s ability to maintain an airway independently and respond appropriately to physical stimulation and verbal command.  DEEP SEDATION-  A controlled state of depressed consciousness, accompanied by partial loss of protective reflexes, including inability to respond to a verbal command.  GENERAL ANESTHESIA-  A controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including inability to maintain an airway independently and respond purposefully to physical stimulation or verbal command  Contra indicated  Long-term exposure (more then 24 hours) can produce transient bone marrow depression.  Patient’s inability to perform nasal respiration because of obstruction from a cold, deviated septum, enlarged adenoids prevents its use.  PREGNANCY Fetal resorption- Congenital abnormalities- Fetal growth retardation  Long surgical procedure(more then 30 min)  DURING TREATMENT  1.The practitioner should be trained in the use of sedation methods.  2. Two members of the dental team should be present.  3. Blood pressure, heart, and respiratory rates should be continuously monitored by trained personnel and intermittently recorded.  4.Child’s color should be visually checked, especially oral mucosa and nailbeds for cyanosis.  5. Head position should be evaluated constantly  POSTOPERATIVE CARE  1. Vital signs should be recorded at intervals after the procedure.  2. Discharge of patient should occur only when a vital signs are stable and patient is alert, can talk, and can sit up unaided  Patient with certain physical, mental, or medically compromising condition.  Patient wherein local anesthesia is not effective or allergic to it.  Fearful, uncooperative, anxious patient with no expectation that behaviour will improve.  Patients who have sustained extensive orofacial trauma.  Instruction to patients  Preoperative health assessment  Clinical examination  Doctors order  INSTRUCTION TO PARENTS  The practitioner should provide verbal and written instruction to the parents. It should include explanation of potential/ anticipated postoperative behavior and limitation of activities along with dietary precautions.  PRE-MEDICATION (in a normal child)  OBJECTIVES  -To block unwanted autonomic reflexes.  -To prevent excessive secretions.  -To produce sedation & allay anxiety.  -To facilitate induction of anesthesia & to supplement & reduce the amount of the same to be administered.  1. Verbal and written instruction should be given to parents about preoperative and postoperative care.  2. No milk or solid foods should be eaten after midnight before procedure. [NPO]  3. Only clear liquids should be ingested up to 4 to 8 hours before appointment, depending on age.  4. Vital statistics should be recorded (weight and height).  5. Medical history should be completed.  6. Status of airway should be confirmed.  7. Vital signs, including pulse and blood pressure, should be recorded.  Procedure performed should be explained to patient.  The presence of any bleeding from the oral cavity, extra oral swelling should be checked for.  The patient can de start of with analgesic if pain is present.  The child should be evaluated for the various system like cardiovascular function.  Any instructions regarding the restorative procedure performed should be given.  Fearand anxitey are hand to hand problem of more than 50% of pediatric patients, to over come that for the treatment you should be skilled, and wise enough. Then the treatment success rate is remarkable.. Thankyou for your attention