Child behavior management TECHNIQUES

Are we managing our children’sAre we managing our children’s
behavior or just treating dental cariesbehavior 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 :-
Psychomotor
Emot ional Development
Environmental Influences
PersonalityTraits

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

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:

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.

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 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 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

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 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]

Behavior Management techniques can beBehavior Management techniques can be
broadly classified as:broadly classified as:
Non-Pharmacological Techniques.
Pharmacological Techniques

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

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 DesensitizationSystematic Desensitization ..exposure to..exposure to
hierarchy of fear producing stimulihierarchy of fear producing stimuli
Desensitization : (joseph Wolpe)Desensitization : (joseph Wolpe)

Systematic DesensitizationSystematic 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…gettingAcclimatisation…getting
familiarizedfamiliarized

ModellingModelling
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 reinforcer
Negative 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.
Music
Video
Talking
White noise….
Hypnosis
Breathing

DistractionDistraction
Objectives:
1. decrease the perception of
unpleasantness;
2. avert negative or avoidance
behavior.
Indications: May be used with any
patient.
Contraindications: None.

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 restricted
Towel held over mouth only
Dry Towel held over mouth and nose
Wet Towel held over mouth and nose

Physical RestraintsPhysical Restraints
Considerations:-
Informed consent
Type of restraint used
Indication for restraint

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

Mouth propsMouth props
WRAPPED/PADDED TONGE BLADE
Use, disposable, inexpensive
OPEN-WIDE MOUTH PROP
Easy 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 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

Body RestrainsBody Restrains
Pedi wrap:-
 Has nylon sheet
 No head supports/
back board
 Various sizes
 Movement
 Mesh fabric –
ventilation( no
hyperthermia)
 Requires straps

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

HeadHead
 Supports the head
 Protects the pt from getting injured himself & pt.
Types:
 Fore body support
 Head protector
 Extra assistant

Practical ConsiderationsPractical Considerations ofof
BEHAVIOR MANAGEMENTBEHAVIOR MANAGEMENT

Dental Clinic setupDental Clinic setup

Convenience of the child
Convenience of the dentist
PEER grouping
SchedulingScheduling

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."

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 PharmacologicalNeed of Pharmacological
interventionintervention

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

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).

STAGES OF ANESTHESIASTAGES OF ANESTHESIA
I stage of analgesia
II stage of delirium
III stage of surgical anesthesia
IV stage of respiratory paralysis

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

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

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 dayAmbulatory out-patient or day
care anesthesiacare anesthesia

Levels of Conscious SedationLevels of Conscious Sedation

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

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

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.

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 GuidelinesPreprocedural 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,]

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

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 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

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

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

INTRA NASAL/INTRA NASAL/
SUBMUCOSAL subcutaneousSUBMUCOSAL subcutaneous

Common agents used forCommon 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]

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

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

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

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.

Child behavior management TECHNIQUES

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