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Child behavior management TECHNIQUES


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Child behavior management TECHNIQUES

  1. 1. Child behaviorChild behavior
  2. 2. Are we managing our children’sAre we managing our children’s behavior or just treating dental cariesbehavior or just treating dental caries ??
  3. 3.  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
  4. 4. Normal behaviour :-Normal behaviour :- Psychomotor Emot ional Development Environmental Influences PersonalityTraits
  5. 5. Emotion is a state of mental excitement characterized by physiological, behavioral changes and alterations of feelings.
  6. 6. Commonly seen emotions in a childCommonly seen emotions in a child
  7. 7. Cry (Elsbach 1963) Obstinate cry, Frightened cry , Hurt cry, Compensatory cry
  8. 8. AngerAnger
  9. 9. FearFear It 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:
  10. 10. 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
  11. 11. 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.
  12. 12. 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.
  13. 13. Anxiety ScaleAnxiety Scale
  14. 14. 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
  15. 15. Behavior managementBehavior management
  16. 16. Behavior managementBehavior management
  17. 17. Behavior managementBehavior management Behavior 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.
  18. 18. FUNDAMENTALS OF BEHAVIOR MANAGEMENTFUNDAMENTALS OF BEHAVIOR MANAGEMENT Positive approach- Positive statements Team attitude- Friendly and caring Organization- Well organized dental team and treatment Truthfulness- Black or White ,nothing gray Tolerance- Ability to rationally cope with the misbehaviors Flexibility-as situation demands
  19. 19. CLASSIFYING CHILDREN'S BEHAVIORCLASSIFYING CHILDREN'S BEHAVIOR Wright's clinical classification (1975) Cooperative Lacking in cooperative ability Potentially cooperative .
  20. 20. Potentially cooperativePotentially cooperative Uncontrolled/Hysterical, Defiant/obstinate, Tense-cooperative, Timid/shy, Whining, and Stoic behavior
  21. 21. 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.
  22. 22. 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: influenced by home environment - throws temper-tantrums and is rebellious. d) Nervous or fearful: The child is tense and anxious, fears dentistry.
  23. 23. 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
  24. 24. Factors affecting ChildsFactors affecting Childs behaviorbehavior Under the control of dentist Under the control of parents – Maternal anxiety and attitudes [Overprotective, Overindulgent, Under affectionate, Rejecting, authoritarian] Others [socioeconomic status, nutritional,past dental experience]
  25. 25. Behavior Management techniques can beBehavior Management techniques can be broadly classified as:broadly classified as: Non-Pharmacological Techniques. Pharmacological Techniques
  26. 26. Non-pharmacological methods 1. Communication 2. Behavior shaping (modification) a. desensitization b. modelling c. contengency management 3. Behavior management a. audioanalgesia b. biofeedback c. voice control d. hypnosis e. humor f. coping g. relaxation h. implosion therapy i. Aversive conditioning
  27. 27. CommunicationCommunication
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. Systematic DesensitizationSystematic Desensitization ..exposure to..exposure to hierarchy of fear producing stimulihierarchy of fear producing stimuli Desensitization : (joseph Wolpe)Desensitization : (joseph Wolpe)
  32. 32. Systematic DesensitizationSystematic Desensitization ..exposure to..exposure to hierarchy of fear producing stimulihierarchy of fear producing stimuli
  33. 33. 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.
  34. 34. 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.
  35. 35. Acclimatisation…gettingAcclimatisation…getting familiarizedfamiliarized
  36. 36. ModellingModelling Bandura (1969) – Live – Filmed – Posters – Audiovisuals
  37. 37. ModelingModeling Allowing the patient to observe one or more individuals [models] Patient frequently imitates the models
  38. 38. Contingency managementContingency management Positive reinforcer Negative reinforcers – Social – Material – Activity
  39. 39. 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. .
  40. 40. 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
  41. 41. Enhancing control..STOP SIGNALEnhancing control..STOP SIGNAL
  42. 42. 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.
  43. 43. RetrainingRetraining To review and retrain the response to a given set of stimuli
  44. 44. DistractionDistraction Diverting the patient’s attention from what may be perceived as an unpleasant procedure. Music Video Talking White noise…. Hypnosis Breathing
  45. 45. DistractionDistraction Objectives: 1. decrease the perception of unpleasantness; 2. avert negative or avoidance behavior. Indications: May be used with any patient. Contraindications: None.
  47. 47. 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.
  48. 48. 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.
  49. 49. 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.
  50. 50. Several variations of home:Several variations of home: HOMAR: HOM with airway restricted HOM and nose with airway restricted Towel held over mouth only Dry Towel held over mouth and nose Wet Towel held over mouth and nose
  51. 51. Physical RestraintsPhysical Restraints Considerations:- Informed consent Type of restraint used Indication for restraint
  52. 52. OralOral  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
  53. 53. Bite blocksBite blocks
  54. 54. Mouth propsMouth props WRAPPED/PADDED TONGE BLADE Use, disposable, inexpensive OPEN-WIDE MOUTH PROP Easy to use, disposable , different sizes, expensive
  55. 55. Molt Mouth propsMolt Mouth props
  56. 56. Restrains - BodyRestrains - Body  Restrict the pt movements  Used frequently in pt < 2yrs of age Papoose board:- Advantages:  Store / use  Size(3)  Reusable
  57. 57. Body RestrainsBody 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
  58. 58. Body RestrainsBody Restrains Pedi wrap:-  Has nylon sheet  No head supports/ back board  Various sizes  Movement  Mesh fabric – ventilation( no hyperthermia)  Requires straps
  59. 59. Restrain : ExtremitiesRestrain : Extremities Attach to the dental unit restraint a pt at the chest waist, legs. Mentally / physically handicapped Prevent the pt from getting injured himself Prevent from interfering in the dental procedure. – Posey straps – Velcro straps – Towel & tape – Extra assistant
  60. 60. HeadHead  Supports the head  Protects the pt from getting injured himself & pt. Types:  Fore body support  Head protector  Extra assistant
  61. 61. Practical ConsiderationsPractical Considerations ofof BEHAVIOR MANAGEMENTBEHAVIOR MANAGEMENT
  62. 62. Dental Clinic setupDental Clinic setup
  63. 63. Convenience of the child Convenience of the dentist PEER grouping SchedulingScheduling
  64. 64. ParentalParental 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."
  65. 65. 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.
  66. 66. Need of PharmacologicalNeed of Pharmacological interventionintervention
  67. 67. GoalsGoals To facilitate the provision of quality care Minimize extremes of disruptive behavior To promote a positive psychologic response to treatment To promote patient welfare and safety
  68. 68. Patient Physical StatusPatient 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).
  69. 69. STAGES OF ANESTHESIASTAGES OF ANESTHESIA I stage of analgesia II stage of delirium III stage of surgical anesthesia IV stage of respiratory paralysis
  70. 70. Conscious sedation ASDAConscious 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
  71. 71. Deep sedationDeep 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
  72. 72. 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
  73. 73. Ambulatory out-patient or dayAmbulatory out-patient or day care anesthesiacare anesthesia
  74. 74. Levels of Conscious SedationLevels of Conscious Sedation
  75. 75. Indications of C.SIndications of C.S Objectives Indications Contraindications  mood alteration  patient should be conscious  respond to verbal stimuli Intact reflexes Vital signs stable and normal Pain threshold increased amnesia  uncooperative patients Cannot understand definitive treatment  lack of psycho- logical or emotional maturity  fearful & anxious  COPD  Epilepsy  bleeding disorders  prolonged surgery
  76. 76. Pre-requisitesPre-requisites Knowledge about the agent Documented rationale Informed consent Office facilities Mobile emergency medical facilities Patient selection and preparation Medical history and patient evaluation
  77. 77. Patient Assessment Prior ToPatient 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.
  78. 78. 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
  79. 79. Preprocedural Fasting GuidelinesPreprocedural Fasting Guidelines To Minimize Aspiration RiskTo Minimize Aspiration Risk
  80. 80. ROUTES OF ADMINISTRATIONROUTES OF ADMINISTRATION Inhalation Enteral [ oral and rectal] Parenteral [ IM, IV, IN, Submucosal, sub cutaneous,]
  81. 81. InhalationInhalation Indications Contraindications Advantages Disadvantages Anxiety Medicall y compromis ed patients Gagging Severe behavioral problems Acute respiratory conditions COPD Pregnancy Rapid onset Peak clinical actions Titration permitted Depth of sedation can be altered Rapid recovery Cost Space Potency Training of staff Occupatio nal hazard
  82. 82. 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]
  83. 83. Oral routeOral route Advantages Disadvantages Universally accepted Easy Low cost Low incidence of reactions No pricks No equipments No special training Reliance Prolonged latent period Erratic & incomplete absorption Inability to titrate Prolonged duration of action
  84. 84. RectalRectal Indications Advantages Disadvantages Unwilling to take orally Nausea & vomitting Patient objecting injection Post-op control of pain Low cost Easy No pricks Absorb directly into systemic circulation Bypassing entero hepatic circulation Inconvenience Variable absorption Inability to reverse Inability to titrate
  85. 85. Intra muscular routeIntra muscular route Advantages Disadvantages Complications Rapid onset:15m Maximum clinical effect : 30m More reliable absorption Inability to titrate Inability to reverse Prolonged duration Injection needed Possible injury Nerve injury Intra-vascular injection Air embolism Periostitis Hematoma Abscess Cyst Necrosis
  86. 86. INTRA NASAL/INTRA NASAL/ SUBMUCOSAL subcutaneousSUBMUCOSAL subcutaneous
  87. 87. Common agents used forCommon agents used for sedationsedation
  88. 88. 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]
  89. 89. AntihistaminesAntihistamines Diphenhydramine Promethazine Hydroxyzine Dosage: oral/IM/ IV 1 to 1.5mg/kg Max 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
  90. 90. 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
  91. 91. 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
  92. 92. 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
  93. 93. Reversal AgentsReversal Agents -,
  94. 94. 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.
  95. 95. 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
  96. 96. PropofolPropofol This 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
  97. 97. 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.