child behavior management techniques
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Child behaviorChild behavior
Are we managing our children’s Are we managing our children’s behavior or just treating dental caries behavior or just treating dental caries
??
Behaviour: Is an observable act, which can be described
in similar ways by more than one person.
”It is defined as any change observed in the functioning
of the organism.”
Behavioural pedodontics:- It is a study of science which
helps to understand development of fear, anxiety and
anger as it applies to child in the dental situations
Normal behaviour :-Normal behaviour :-Ps
ycho
mot
or
Emotional Development
Environmental Influences
Personality Traits
Emotion is a state of mental excitement characterized by physiological, behavioral changes and alterations of feelings.
Commonly seen emotions in a childCommonly seen emotions in a child
Cry (Elsbach 1963)
Obstinate cry,Frightened cry ,Hurt cry, Compensatory cry
AngerAnger
FearFearIt may be defined as an unpleasant emotion or effect
consisting of psycho-physiological changes in response to realistic threat or danger to one's own experience.
Innate fear Subjective fear Objective fear:
Fear Evoking Dental Stimuli…
Factors Causing Dental Fear
1. Fear of pain or its anticipation.
2. A lack of trust or fear of betrayal.
3. Fear of.1oss of control.
4. Fear of the unknown.
5. Fear of intrusion.
SIGNS AND SYMPTOMS OF FEAR
AnxietyAnxiety
Is an emotion similar to fear arising without any objective source of danger. Is a reaction to unknown danger.
It is often been defined as a state of unpleasant feeling combined with an associated feeling of impending doom or danger from within rather than from without.
It is a learned process being in response to one's environment. As anxiety depends on the ability to imagine, it develops later than fear.
Types of anxietyTypes of anxiety Trait anxiety temperament feature. These children are
generally jittery, hypersensitive to stimuli.
Free floating anxiety- persistently anxious mood
Situational anxiety- Seen only to specific situations or objects.
State anxiety-
General anxiety -a chronic pervasive feeling of anxiousness whatever the external circumstances.
Anxiety ScaleAnxiety Scale
Phobia:Phobia: Defined as persistent, excessive, unreasonable fear
of a specific object, activity or situation that results in a compelling desire to avoid the dreaded object.
Simple Situational Social
Behavior managementBehavior management
Behavior managementBehavior management
Behavior managementBehavior managementBehavior management is the means by
which the dental health team effectively and efficiently performs treatment for a child and, at the same time, instills a positive dental attitude.
The fundamentals of behavior management center on the attitude and integrity of the entire dental team.
FUNDAMENTALS OF BEHAVIOR MANAGEMENTFUNDAMENTALS OF BEHAVIOR MANAGEMENT
Positive approach- Positive statementsTeam attitude- Friendly and caringOrganization- Well organized dental team and
treatment Truthfulness- Black or White ,nothing grayTolerance- Ability to rationally cope with the
misbehaviors Flexibility-as situation demands
CLASSIFYING CHILDREN'S BEHAVIORCLASSIFYING CHILDREN'S BEHAVIOR
Wright's clinical classification (1975)
Cooperative
Lacking in cooperative ability
Potentially cooperative
.
Potentially cooperativePotentially cooperative
Uncontrolled/Hysterical, Defiant/obstinate, Tense-cooperative, Timid/shy, Whining, and Stoic behavior
Frankel’s Behavioral Rating Scale. Frankel’s Behavioral Rating Scale. (1962)(1962) 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.
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.
Rating 4: Definitely Positive. Good rapport with the dentist, interest in the dental procedures, laughter and enjoyment.
Wilson's classification (1933)Wilson's classification (1933)
a) Normal or bold: The child is brave enough to face new situations, is co-operative, and friendly with the dentist.
b) Tasteful or timid: The child is shy, but does not . interfere with the dental procedures.
c) Hysterical or rebellious: Child.is influenced by home environment - throws temper-tantrums and is rebellious. d) Nervous or fearful: The child is tense and
anxious, fears dentistry.
Lampshire Classification (1970)Lampshire Classification (1970)1. Co-operative: The child is physically and emotionally relaxed. Is
cooprative throughout the entire procedure
2. Tense cooperative: The child is tensed, and cooperative at the same time.
3. Outwardly apprehensive: Avoids treatment initially, . usually hides behind the mother, avoids looking or talking to the dentist. Eventually accepts dental treatment.
4. Fearful: Requires considerable support so as to overcome the fears of dental treatment.
5. Stubborn/Defiant: Passively resists treatment by using techniques that have been successful in other situations.
6. Hypermotive: The child is acutely agitated and resorts to screaming kicking etc.
7. Handicapped: Physically/mentally, emotionally handicapped.
8. Emotionally immature
Factors affecting Childs Factors affecting Childs behavior behavior
Under the control of dentistUnder the control of parents
– Maternal anxiety and attitudes [Overprotective, Overindulgent, Under affectionate, Rejecting, authoritarian]
Others [socioeconomic status, nutritional,past dental experience]
Behavior Management techniques can be Behavior Management techniques can be broadly classified as:broadly classified as:
Non-Pharmacological Techniques.
Pharmacological Techniques
Non-pharmacological methods1. Communication2. Behavior shaping (modification)
a. desensitizationb. modellingc. contengency management
3. Behavior managementa. audioanalgesiab. biofeedbackc. voice controld. hypnosise. humorf. copingg. relaxationh. implosion therapyi. Aversive conditioning
CommunicationCommunication
CommunicationCommunication Verbal [establishment of communication,
establishment of communicator ,message clarity,tone]
Nonverbal [Multi sensory Communication]
Problem Ownership –Use “I” messages,
Active Listening
Appropriate Responses to the situation
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
Behavior shapingBehavior 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 Systematic Desensitization ..exposure to ..exposure to hierarchy of fear producing stimuli hierarchy of fear producing stimuli
Desensitization : (joseph Wolpe)Desensitization : (joseph Wolpe)
Systematic Desensitization Systematic Desensitization ..exposure to ..exposure to hierarchy of fear producing stimulihierarchy of fear producing stimuli
Tell-show-do[ Addelston]Tell-show-do[ Addelston] 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-doTell-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 Acclimatisation…getting familiarizedfamiliarized
Modelling Modelling
Bandura (1969)
– Live– Filmed – Posters – Audiovisuals
ModelingModeling
Allowing the patient to observe one or more individuals [models]
Patient frequently imitates the models
Contingency managementContingency management
Positive reinforcerNegative reinforcers
– Social– Material– Activity
Positive reinforcementPositive 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..
3. Behavior management3. 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
Enhancing control..STOP SIGNALEnhancing control..STOP SIGNAL
Voice ControlVoice Control Voice control is a controlled alteration of
voice volume, tone, or pace to influence and direct the patient’s behavior.
Objectives:1. gain the patient’s attention and
compliance;2. avert negative or avoidance behavior;3. establish appropriate adult-child roles.
RetrainingRetraining
To review and retrain the response to a given set of stimuli
DistractionDistraction
Diverting the patient’s attention from what may be perceived as an unpleasant procedure.
MusicVideoTalkingWhite noise….HypnosisBreathing
DistractionDistraction
Objectives:1. decrease the perception of
unpleasantness;2. avert negative or avoidance behavior.
Indications: May be used with any patient.
Contraindications: None.
AVERSIVE CONDITIONING
Informed consentInformed 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.
HOMEHOME 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.
HOMEHOME.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:Several variations of home:
HOMAR: HOM with airway restricted HOM and nose with airway restrictedTowel held over mouth onlyDry Towel held over mouth and noseWet Towel held over mouth and nose
Physical Restraints Physical Restraints
Considerations:-Informed consentType of restraint usedIndication for restraint
Oral Oral
At the time of injection For stubborn child/ defiant child Mentally handicapped child Very young child who cannot keep its mouth open
for long time
Bite blocksBite blocks
Mouth props Mouth props
WRAPPED/PADDED TONGE BLADEUse, disposable, inexpensive
OPEN-WIDE MOUTH PROPEasy to use, disposable , different sizes, expensive
Molt Mouth propsMolt Mouth props
Restrains - BodyRestrains - Body
Restrict the pt movements Used frequently in pt < 2yrs of age
Papoose board:-Advantages: Store / use Size(3) Reusable
Body Restrains Body Restrains
Triangular sheet with leg straps:- Mink – bed sheet / triangular sheet technique Advantage:
– sit upright
Disadvantages: Need of straps Difficult for small children Airway impingement hyperthermia
Body RestrainsBody RestrainsPedi wrap:- Has nylon sheet
No head supports/ back
board
Various sizes
Movement
Mesh fabric – ventilation(
no hyperthermia)
Requires straps
Restrain : ExtremitiesRestrain : ExtremitiesAttach to the dental unit restraint a pt at the chest
waist, legs.Mentally / physically handicapped Prevent the pt from getting injured himselfPrevent from interfering in the dental procedure.
– Posey straps– Velcro straps– Towel & tape– Extra assistant
Head Head Supports the head Protects the pt from getting injured himself & pt.
Types: Fore body support Head protector Extra assistant
Practical Considerations Practical Considerations of of BEHAVIOR MANAGEMENTBEHAVIOR MANAGEMENT
Dental Clinic setupDental Clinic setup
Convenience of the childConvenience of the dentistPEER grouping
SchedulingScheduling
Parental Parental presence/absencepresence/absence
The parent often repeats orders, injects orders,
The dentist is unable to use voice
intonation, divides attention between the parent and child.
The child divides attention between the parent and dentist.
"performing with an audience."
Parental presenceParental presence A parent can be a major
asset in supporting and communicating with a disabled child,
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.
Need of Pharmacological Need of Pharmacological intervention intervention
GoalsGoals
To facilitate the provision of quality careMinimize extremes of disruptive behaviorTo promote a positive psychologic response
to treatmentTo promote patient welfare and safety
Patient Physical Status Patient Physical Status ClassificationClassification
ASA I - A normal healthy patient. (ASA = American Society of Anesthesiologists) ASA II - A patient with mild systemic disease. ASA III - A patient with severe systemic disease. ASA IV - A patient with severe systemic disease that is a constant threat to life. ASA V - A moribund patient who is not expected to survive without the
operation. ASA VI - A declared brain-dead patient whose organs are being removed for
donor purposes. E - Emergency operation of any variety (used to modify one of the above
classifications, i.e., ASA III-E).
STAGES OF ANESTHESIA STAGES OF ANESTHESIA
I stage of analgesiaII stage of deliriumIII stage of surgical anesthesiaIV stage of respiratory paralysis
Conscious sedation ASDA Conscious sedation ASDA 19851985
Minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command, produced by pharmacologic and nonpharmacologic methods alone or in combination
Deep sedation Deep sedation
A controlled state of depressed consciousness accompanied by a partial loss of protective reflexes including inability to respond purposefully to a verbal command, produced by pharmacologic and nonpharmacologic methods alone or in combination
General anesthesiaGeneral anesthesia
A controlled state of unconsciousness accompanied by partial or complete loss of protective reflexes including inability to maintain airway independently and respond purposefully to physical stimulation or verbal command, produced by pharmacologic and nonpharmacologic methods alone or in combination
Ambulatory out-patient or day Ambulatory out-patient or day care anesthesiacare anesthesia
Levels of Conscious SedationLevels of Conscious Sedation
Indications of C.SIndications of C.SObjectives Indications Contraindications
mood alteration patient should be conscious respond to verbal stimuliIntact reflexesVital signs stable and normalPain threshold increasedamnesia
uncooperative patientsCannot understand definitive treatment lack of psycho-logical or emotional maturity fearful & anxious
COPD Epilepsy bleeding disorders prolonged surgery
Pre-requisitesPre-requisites
Knowledge about the agentDocumented rationaleInformed consentOffice facilitiesMobile emergency medical facilitiesPatient selection and preparationMedical history and patient evaluation
Patient Assessment Prior To Patient Assessment Prior To Conscious SedationConscious Sedation
The physician, dentist, or independent practitioner responsible for overall conduct of the conscious sedation is generally required to do the following within 30 days prior to procedural sedation:– perform a history and physical exam– assign an American Society of Anesthesiologist (ASA)
health class– document a sedation plan– document NPO status and interval changes if H&P not
done immediately prior to procedure.
Focused History and ExamFocused History and Exam
History should focus on factors that may increase– patient sensitivity to sedatives/analgesics– patient risk of respiratory/cardiopulmonary
complications– difficulty in managing complications
Preprocedural Fasting Guidelines Preprocedural Fasting Guidelines To Minimize Aspiration RiskTo Minimize Aspiration Risk
ROUTES OF ADMINISTRATIONROUTES OF ADMINISTRATION
Inhalation Enteral [ oral and rectal]Parenteral [ IM, IV, IN, Submucosal, sub
cutaneous,]
InhalationInhalationIndications Contraindications Advantages Disadvantages
AnxietyMedically compromised patientsGagging
Severe behavioral problemsAcute respiratory conditionsCOPDPregnancy
Rapid onsetPeak clinical actionsTitration permittedDepth of sedation can be alteredRapid recovery
CostSpace PotencyTraining of staffOccupational hazard
Nitrous oxide and oxygenNitrous oxide and oxygen
sp gr 1.53,low solubility in blood, rapid onset , no bio transformation,excreted by lungs
Adverse effects [ N2O Entraped in gas filled spaces]
Oral routeOral routeAdvantages Disadvantages
Universally acceptedEasyLow costLow incidence of reactionsNo pricksNo equipmentsNo special training
RelianceProlonged latent periodErratic & incomplete absorptionInability to titrateProlonged duration of action
Rectal Rectal Indications Advantages Disadvantages
Unwilling to take orallyNausea & vomittingPatient objecting injectionPost-op control of pain
Low costEasyNo pricksAbsorb directly into systemic circulationBypassing entero hepatic circulation
InconvenienceVariable absorptionInability to reverseInability to titrate
Intra muscular routeIntra muscular routeAdvantages Disadvantages Complications
Rapid onset:15mMaximum clinical effect :30mMore reliable absorption
Inability to titrateInability to reverseProlonged durationInjection neededPossible injury
Nerve injuryIntra-vascular injectionAir embolismPeriostitisHematomaAbscessCystNecrosis
INTRA NASAL/ INTRA NASAL/ SUBMUCOSAL subcutaneousSUBMUCOSAL subcutaneous
Common agents used for Common agents used for sedationsedation
Common agents used for sedationCommon agents used for sedation Gases Antihistamines
[Hydroxyzine ,Promethazine,Diphenhydramine] Benzodiazepines
[Diazepam , Midazolam, lorazepam] Benzodiazepines Antagonist [Flumazenil] Sedative Hypnotics [Barbiturates ,Chloral Hydrate] Narcotics [Meperidine ,Fentanyl] Narcotic Antagonist [Naloxone] Dissociative agent [Ketamine] Others [Propofol]
AntihistaminesAntihistaminesDiphenhydramine Promethazine Hydroxyzine
Dosage: oral/IM/ IV1 to 1.5mg/kgMax dose = 50mg
Dosage : oral/ IM – 0.5 to 1.1 mg/kg. SC not recommended. Max. recommended dose is 25mg
Supplied tablet syrup and injectable form
Dosage :Oral : 1-2mg/kg
IM : 1.1mg/kg
Supplied : Tabs 10, 25, 50, 100mg
Syrup 10mg/ 5ml
Injectable 25 or 50mg/ml
BenzodiazepineBenzodiazepine
Diazepam Midazolam
Dosage : 0.2 to 0.5mg/ kg ;
max single dose 10mg;
IV 0.25mg/kg
Dosage : 0.25 to 1mg/kg
max single dose 20mg
IM 0.1 to 0.15mg/kg
max 10mg;
IV - manufacturer's recommendation
Sedative HypnoticsSedative Hypnotics
Barbiturates Chloral hydrate
Limited value for pediatric patients
Must be individualized for each
Recommended 25-50mg/kg to a max of 1g supplied in the form of oral capsules 500mg
Oral solution 250 and 500mg/ 5ml
Rectal suppositories 324 and 648mg
NarcoticsNarcotics
Meperidine Fentanyl
Oral/ SC/ IM – 1 to 2.2mg/kg not to exceed 100mg
Supplied : oral tablets 50 and 100mg
Oral syrup 50mg/ 5ml
Parenteral solution 25, 50, 75 and 100mg/ ml
0.002 to 0.004mg/ kg
Supplied 0.05mg/ ml in 2 and 5ml ampules
Reversal AgentsReversal Agents-,
Ketamine [ Dissociative agent]Ketamine [ Dissociative agent]
Derivative of the street drug phencyclidine. This drug carries an increased risk of deep sedation
and should be used only by those with hospital privileges in deep sedation.
Induces a functional dissociation between the cortical & limbic systems to create a sensory isolation and “trance-like” state.
A potent pain reliever as the drug prevents cortical interpretation of noxious stimuli.
KetamineKetamine
Produces CNS stimulation & inhibits catecholamine uptake, so direct myocardial depressant effects are overcome.
While producing sedation, amnesia, & analgesia, ketamine may also produce dreams & delirium. This is minimized by co-administering small doses of midazolam.
1 TO 4.5mg/kg IV over 1min
PropofolPropofolThis drug carries an increased risk of progression to
deep sedation and should be used only by those with hospital privileges in deep sedation.
no analgesic properties but does produce sedation and amnesia.
widely distributed in the body and is eliminated via hepatic & pulmonary systems.
DOSE 1mg/kg /iv followed by 3 to 4.5 mg /kg/hr
The Lytic CocktailThe Lytic Cocktail
A fixed combination of meperidine, promethazine, and chlorpromazine.
Long history of use in pediatric sedation. Commonly called DPT, an acronym for demerol,
phenergan, and thorazine. Its use is strongly discouraged; equivalent or
superior sedation may be achieved with single agents or individualized combinations of sedatives & narcotics.