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Behaviour management; aversive conditioning, h.o.m.e, reinforsment

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Behaviour management; aversive conditioning, h.o.m.e, reinforsment

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Behaviour management; aversive conditioning, h.o.m.e, reinforsment

  1. 1. BEHAVIOUR MANAGEMENT Aversive conditioning, Flooding, Negative Reinforcement, Positive Reinforcement and H.O.M.E HAYAT ALGHUTAIMEL UNIVERSITY OF LEEDS MARCH 2016
  2. 2. 2 TABLE OF CONTENT 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 2. Classifyingchildren cooperativebehaviour .. . . . . . . . . . . . . . . . . . . . . . . . . . 03 3. Functional Inquiry .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 4. Anexiety, Fear and Dental Phobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04 2. Behaviour Management Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05 3. PositiveReinforcement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 4. Aversive Conditioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06 5. Negative Reinfocement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07 6. Hand Over Mouth Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07 7. Flooding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08 8. Summary: So, Positiveor Negative Reinforcement? . . . . . . . . . . . . . . . 09 9. Refrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
  3. 3. 3 INTRODUCTION In 1895 McElory wrote, “Although the operative dentistry may be perfect, the appointment is a failure if the child departs in tears". This was the first mention in the dental literature of measuring the success or failure of a child’s appointment by anything other than technical proficiency. One of the most important skills that a paediatric dentist must learn is the ability to guide paediatric patients through their dental journey without subjectingthem to negative experiences. In fact, behaviour management influences the attitude of children towards dental treatment, and consequently their future dental health. Promoting a positivedental attitude requires a good communication and relationship based on trust between the dentist,parent/caregivers,and the child;the paediatric triangle.Behaviour guidancetechniques can beboth pharmacological and non-pharmacological or a combination of both. However,no one method can beapplicable to all situations,thus thevarious techniques mustbe tailored to individual patients and practitioners. (American Academy of Paediatric Dentistry,2011) (Campell et al, 2011). Classifying children cooperative behaviour Numerous systems have been developed to classifyingthebehaviour of the children in the dental environment. The knowledge of these systems can be an asset to the dentist in several ways: It can assist in directing the management method, it can provide a means for systematically recording behaviour, and It can assist in evaluatingthe validity of current research. 1. Wright’s clinical classification places children in three categories:  Cooperative  Lackingin cooperative ability  Potentially cooperative Cooperative children are reasonably relaxed.They have minimal apprehension.They may be enthusiastic. They can be treated by straightforward, behaviour-shaping approach. When guidelines for behaviour established,they perform within the framework provided. Lackingin co-operative ability refers to children who are too young with whom communication cannot be established or those with specific disabilities with whom cooperation may never be achieved. Potentially cooperative children arethose who are havingsome behaviour problems. However, they have the capability to perform cooperatively after the useof behavior modification techniques. 2. Frankl behavioural ratingscale: The scaledivides theobserved behaviour in to four categories,rangingfromdefinitely negativeto definitely positive (table:1). A shortcoming of this method is that the scale does not communicate sufficient clinical information regardinguncooperative children.Therefor, the user of this scalemust qualify and categorize the child’s reaction,specially if thechild is judgeas (-) or (--).
  4. 4. 4 1 - - Definitely negative Refusal of treatment, forceful crying,fearfulness,or any other overt evidence of extreme negativism. 2 - Negative Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pronounced (sullen,withdrawn). 3 + Positive Acceptance of treatment; cautious behaviour attimes; willingness to comply with the dentist, at times with reservation, but patient follows the dentist’s directions cooperatively. 4 + + Definitely positive Good rapportwith the dentist, interest in the dental procedures, laughter and enjoyment. Functional Inquiry After obtainingmedical and dental history,a functional inquiry conduction ishighly recommended from behavioural pointof view. Itcan be obtained usually by either questionnaireor direct interview. During interview, consider the followingquestions:  How do you think your child has reacted to pastmedical procedures?  How do you rate your own anxiety at the moment? (because parental anxiety usually transmitted to their child)  Does your child think there is anythingwrong with his or her teeth? (there is tendency toward negative behaviour when the child believes that a dental problem exists,McDonald et.al.2004)  How do you expect your child to react in the dental chair?  What school do your child attend?  Do you expect your child to be advanced in learning, progressing normally or a slow learner? (It is of paramount importance that the level of the child’s cognitive development is assessed before behavioural / communicative management techniques are applied. (American Academy of Paediatric Dentistry, 2011) Other avenues that can be explored includerewards and consequences used in the home environment. These provideinsightin to the type of behavioural management techniques that would be acceptableto the parent. Anxiety, Fear and Phobia A good understandingof the difference between anxiety, fear and phobia is required beforechoosingbehaviour management strategies. Anxiety is a reaction child would exhibitto an unknown, ill-defined or not immediately present danger. Fear is the trigger of the stress responsesystem as a reaction to a known perceived threat or danger. Fears are normal aspectof development and temporary in nature. (The national scientific council of the developing child, 2010) Table 1: Frankl behavioural ratingscale
  5. 5. 5 Phobia is havingan unreasonableand excessivepersistentfear of an object or a situation leadingto avoidance of that situation.Phobia often causes distress thatinterferes with normal functioning.Itislesslikely thatchildren with no previous dental experiences will be phobic. (MacLeavy, 2008) Dental phobia can bebest explained with what is called fear conditioning.Thatis,pairinga neutral stimulus(i.e. going to the dentist), which does not usually elicita negativeemotional responseto aversivestimulus (i.e.pain) that produces fear. Conditioned fear is not simply forgotten overtime, but it has to be unlearned. One way of actively unlearningnegativefear responses to a specific stimulusisby introducingthe aversivestimulus ata low level of intensity whilethe fearful individual isin a safecontext. (The national scientific council of thedeveloping child,2010) This cognitive behavioural therapy is similar to floodingand systematic desensitization techniques practiced in dentistry for the management of dental fear and phobia. Every effort should be made to reduce fear and prevent phobia in the firstplace.It is notalways possiblefor all procedures to be painless or totally comfortable for patients, but good behaviour guidance accompanied with empathy, compassion and positive body language, would decrease the likelihood of developing a persistent negative impact. (Duggal et al, 2013) It is well known that communication is mostly about our body languages and the volume, tone and rhythm of our voices.What we say only count for 7% of the communication process. Verbally reassuringpatients,only reassures clinicians rather than patients. It is how it is said rather than what, that is important. (Bellis,2013) Behaviour Management Techniques Behaviour management is the mean by which the dental health team effectively and efficiently perform treatment for the child,and at the same time instil a positivedental attitude. Basic non-pharmacological behaviour management techniques based on positivereinforcement include: (Duggal et al, 2013)  Tell-show-do  Behaviour shaping  Modeling  Distraction Basic behaviour management approaches are not always sufficient to manage some patients and more specialized and complex approaches aresometimes required. Too anxious children,children who had negative pastdental experiences,those who areused to havingtheir own way athome or those who arephobic to certain aspects of dental treatment; are often difficult to manage with just basic management skills. Those complex strategies are based on aversive conditioning and include: negative reinforcement, floodi ng and hand over mouth exercise(H.O.M.E). (Duggal et al, 2013) When all of the above behaviour management techniques fail to achieve desired cooperation,pharmacological behaviour management strategies such as sedation areused wherever suitable.Inhalati on sedation with nitrous oxide is the most popular type of sedation used in the UK. For very young children,disabled patients,patients with complex medical conditions or complex cases, treatment can be performed under general anesthesia as the lastor only resort.
  6. 6. 6 Positive Reinforcement Positive reinforcement involves rewarding good behaviours and strengthening their occurrence as well as ignoringnegative behaviour.In order for that to be effective, itis advised thatappraisinggood behaviour takes placeimmediately followingany behaviour that the dentist is attempting to strengthen. (MacLeavy, 2008) The more immediate the reinforcement follows the response,the stronger the association between the cue and the response. (Wright,et al 2014) There areno contraindicationsfor this type of reinforcement, in fact it is suitable for every patient who is ableto communicate. (American Academy of Paediatric Dentistry,2011) Stickers or badges given at the end of the appointment are successful methods of selective reinforcement, however, social stimuli arethe most powerful reinforcer. Social stimuli can beverbal or in a form of nodding or smiling. It has been shown that specifically appraising good child’s actions (i.e. I like the way you open your mouth) aremore effective than general comments (you havebeen a good girl today).(Campell atal,2011) (Fayle & Tahmassebi,2003). Aversive Conditioning Aversive conditioningis a formof behaviour therapy in which an aversivestimulus ispaired with an undesirable behaviour in order to reduce or eliminatethat undesirablebehaviour.(Duggal etal, 2013) The aversivestimulus is often an object or event that causes strong feelings of dislikeor disgust.The goal of aversiveconditioningis to establish an emotional statethatwill inhibitor counter theinitial undesirableact. (Strand,2005) Both aversive conditioning and punishment involve the onset of an aversive stimulus following the performance of an unacceptable behaviour, however, concepts are different. Aversive conditioning does not modify the child’s behaviour by simply providingpunishmentbut rather links thatbehavi our to an aversivesensation,which would inhibitthe unpleasantbehaviour. (Strand,2005) Aversive conditioning is indicated in normal children who are older than 3 years and are momentarily uncontrolled. It is contraindicated in patients who lack the cooperative ability, with whom communication cannot be established.Aversiveconditioningaims to:  Establish better communication.  Gain control of behaviour.  Protect the child frominjury  Eventually makes the child’s dental experience a pleasantone. Negative reinforcement, flooding, selective exclusion of parents and H.O.M.E, are all example of aversive conditioning. These approaches are often deployed where all other avenues to establish communication with the child havefailed. Those should not be used routinely,but as a method of lastresort.They are only used on one occasion to establish communication with the child and should be followed by positive reinforcement. (Duggal et al, 2013) Does aversiveconditioningincreasedental fear? Evidence suggests that high levels of fear are most attributed to aversive conditioning during childhood. However, most studies in that field areof poor methodological quality. Most of them are of retrospective type, which makes them vulnerableto recall or memory bias. (Moraes,2002)
  7. 7. 7 Negative reinforcement The process of negative reinforcement involves the removal, reduction, postponement or prevention of stimulation when an undesired action is performed. (Duggal et al, 2013) Removal or reduction of an ongoing stimulation produces a behaviour that is called “escape”. Escape involves respondingin the presence of an undesirablestimulus in order to terminate it. (Iwata, 1987) Postponement and prevention producea behaviour thatis called avoidance,which involves acquiringa response that prevents an aversivestimulus fromoccurring. (Iwata,1987) Hand Over Mouth Exercise (H.O.M.E) Hand over mouth exerciseis a negative reinforcement strategy that is often employed to deal with hysterical or tantrum-likebehaviour to establish an effectivecommunication.It was suggested by some authors thatthis is a method of a lastresortthatshould be employed on children who are healthy and areat leastthree years of age to securetheir attention. (Fayle& Tahmassebi,2003) (Roberts, 2010) When patient cries hysterically,hands areput firmly on the patient mouth without blockingthe airway.This is combined with strict instructions to stop crying for the hand to be removed. When the patient indicates willingness to cooperate, hand is removed and patient is reassessed. Repeat if patient start crying again until behaviour is shaped. (Roa, 2012) Although this might be an effective way of controllingthechild’s behaviour this isan unacceptablebehaviour in the UK. Itcould be very easily misinterpreted as an assaultand perceived as a formof physical restrain. (Fayle& Tahmassebi,2003) (Roberts, 2010) Example: A patient starts cryingon the chair,so you tell parents to waitoutside your surgery. Excluding parents is the negative stimulus and in order for that stimulus to terminate, the patient should stop crying. When your patient stops crying you ask the parents to come back into the room again,which means that you have removed the aversivestimulus. Your patient has “escaped” the negative situation by showingan acceptablebehaviour. Example: Your patientfrom the previous example starts cryingagain.You turn to the parents to ask them to leave, but the patient stops crying this time before the parents leave. Your patient has “avoided” the aversivesituation.
  8. 8. 8 Itis acceptableunder theAAPD guidelines to useH.O.M.E, although incidenceis decreasing. (American Academy of Paediatric Dentistry, 2011) In the UK it is regarded as extreme and unacceptable by the majority of parents and dental practitioners. (Henry, 1984) (Welbury et al, 2012) The GDC guidelines maintaining standard has stated that any form of intimidation isnever justified,and in caseof exceptional circumstancesa special consent is a necessity.(MacLeavy, 2008) (Fayle& Tahmassebi,2003) (American Academy of Paediatric Dentistry,2011) "There can be no justification for intimidation or, other than in the most exceptional circumstances, for the use of physical restraint in dealing with a difficult patient. When faced with a child who is uncontrollable for whatever reason, the dentist should consider ceasing treatment, making an appropriate explanation to the parent or representative and arrange necessary future treatment for the child, rather than continuing in these circumstances." (GDC guidelines maintainingstandards,2001). There is a variation of H.O.M.E where the child’s airway isdeliberately restricted,named hand-over-mouth with airway restriction (HOMAR). This is to be universally condemned and should never be used. (Roberts, 2010) Flooding Flooding is simply exposing patients to their greatest fear without them being harmed or endangered in any way. It is a type of desensitization for the treatment and extinction of dental phobia.(Duggal et al, 2013) In the previous example it might be acceptableto put the child on the chair,butit will notbe a wisedecision to stick a needle in a needle phobic patient to let them facetheir fears. Although, floodinghas gota great chanceof success,it may not be the most adaptivemethod of respondingto a realistic danger. Reducing fear may reduce a child’s future caution in risky situations. Fear is a natural good and protective behaviour which can be excessiveand unreasonableatsome points in life (Bell,2005) . Flooding and systemic desensitization are two major exposure-based techniques that share some of the basic ideas but differ in the approach of which the are applied. a) Fears develop because the individual anticipates that contact with a particular object or event would resultin a negative outcome. b) Both the anxiety and the featured outcome are excessiveand unrealistic. c) Escape or avoidanceof the feared situation is reinforced when the negative outcome does not occur. Escapeand/or avoidancebecome a conditioned responseto the feared stimulus. Example: Helping the child confronting their fears of sitting in the dental chair by placing them in the chair,which allows themto realizethat this was not so threatening after all. (Duggal et al, 2013)
  9. 9. 9 d) A successful treatment would involve breaking the link between the feared stimulus and anxiety and the conditioned response; which is escapeor avoidance. Flooding would break the link between the feared stimulus and the conditioned response. Systematic desensitization on the other hand is more concerned about stimulus and anxiety separation.(Bell,2005) Summary: Positive or Negative Reinforcement? Negative reinforcer strengthen behaviour when they are removed. Positive reinforcer strengthen behaviour when they are present. In both cases the effect of reinforcement is the same - the probability of response is increased. Although punishment and negative reinforcement are both different, negative reinforcement starts by introducing a negative stimulus which is then removed following an acceptable behaviour. Application of an aversivestimuli could beviewed as a formof punishment,and punishmentweakens behaviour. (Baron & Galizio, 2005) In some countries, aversivebehaviour management techniques are acceptable(includingpapooseboards) and are common practice. Could this practicecondition fear in children and grow phobic adults who might be very frightened of visitingthe dentist in the future? The main goal of paediatric dentistry is to promote acceptance of dental treatment, and by the repeated and the unjustified application of such aversive methods,it is fear and anxiety that is promoted. Negative reinforcement (that would not breach the child’s dignity) issuggested,as mentioned above, to be used to gain tantrum patient’s attention and establish communication (i.e.parental exclusion).It is then advised for that to be followed by a positive reinforcement. So, simply speaking, negative gets you started, while positive keeps you going.
  10. 10. 10 REFERENCES  Dean, J.A., 2015.McDonald and Avery's Dentistry for the Child and Adolescent. Elsevier Health Sciences.  American Academy of Paediatric Dentistry.(2011).Guidelineon behaviour guidancefor thepediatric dental patient. 36 (6), 179-191.  Baron, A., & Galizio,M. (2005).Positive and Negative Reinforcement: Should the Distinction BePreserved? The behaviour analyst, 28 (2), 85-98.  Bellis,w. (2013).Managingthe young child patient. Nature - Vital, 10, 26-27.  Bell,J. & Strand, P. (2005) In Encyclopedia of Behavior Modification and CognitiveBehavior Therapy, vol.2: Child Clinical Applications,ed. by Michel Hersen, et al.(Sage Publications,Thousand Oaks,CA,2005)  Campell, C. et al.(2011). Update of Non - pharmacological behaviour management guideline.UK National Clinical guidelines in paediatric dentistry  Duggal, M., et al.(2013).Paediatric Dentistry at a Glance. West Sussex:John wiley and sons,Ltd.  Fayle,S., & Tahmassebi,J. (2003).Paediatric Dentistry in the New Millennium:2. Behaviour Management – HelpingChildren to Accept Dentistry. Dental update, 30, 294-298.  Henry, W. (1984). Acceptability of various behaviour management techniques relative to types of dental treatment. Journal of paediatric dentistry, 6 (4), 199-203.  Iwata, B. (1987). Negative reinforcement in applied behavior analysis. Journal of Applied Behavior analysis, 20 (4), 361-378.  MacLeavy, C. (2008).Who's been a good boy today, then? Nature - Vital, 8, 25-29.  Moraes, A. (2002). Negative and Positive Control in Dental Treatment Situations. Brazilian journal of oral science, 1 (2), 95-98.  National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learningand Development: WorkingPaper No. 9. http://www.developingchild.net  Roa, A. (2012). Principles and practice of pedodontics (3rd Edition ed.). Jaypee Brothers Medical Publishers.  Roberts, J. e. (2010). Review: Behaviour management techniques in paediatric dentistry. European Archives of Paediatric Dentistry, 11 (4), 166-174.  Strand, P. (2005). Aversive conditioning (Vol. 2). CA: Sage.  The national scientific council of the developing child.(2010). persistentfear and anxiety can affect Young children’s learningand Development. Working paper No. 8.  Welbury, R., et al.(2012). Paediatric Dentistry (Vol. 4). Oxford: Oxford University Press.  Wright, et al.(2014). Behaviour management in dentistry for children. Oxford: Wiley.

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