SlideShare a Scribd company logo
Child Behavior
Dr Simran Vangani
2nd year PG
Dept. of Pediatric & preventive Dentistry,MGDCH
1
Introduction
Successful dentistry for children depends not only upon the dentist's
technical skills but also upon his ability to acquire and maintain a child's
cooperation. Most children strive to be cooperative; in these instances,
the dentist should support the child's behaviour.
When a child is uncooperative, however, his behaviour must be altered
and controlled.
2
• Behaviour- is any activity that can be observed, recorded, and measured. It is an
observable act or any change in the functioning of an organism.
• Behavioral pedodontics- is the study of science that helps to understand
development of fear, anxiety, anger, and associated acts as it applies to the child in
the dental situation.
• Behavior guidance- is a continuum of interaction involving the dentist, the dental
team, the patient, and the parent directed toward communication and education
“which ultimately builds trust and allays fear and anxiety”
• 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 (Wright, 1975)
• Behavior modification -is defined as the attempt to alter human behavior and
emotion in a beneficial manner according to the laws of modern learning theory
(Eysenck, 1964)
• ™
Behaviour shaping is the procedure, which slowly develops behavior by reinforcing
a successive approximation of the desired behavior until the desired behavior
comes into being, for example, desensitization, tell–show–do (TSD), modeling,
distraction, contingency management.
3
Classification of child behavior in dental office-
One of the cornerstones in practicing pediatric dentistry is
the ability to guide children positively throughout their dental
experience and encourage a positive dental attitude to
improve their oral health.
Assessment and management of children based on their
behavior are the most important skills for a pediatric dentist.
It is important for pediatric dentists to assess and evaluate
psychological, personal traits, and behavioral responses of the
child, as they play a major role in the management of dental
anxiety and fear.
Evaluation of the child’s behavior serves as an aid in directing
individualized behavior guidance approach that facilitates
dental treatment and provides a means for systematically
recording behaviors for future appointments.
4
• Numerous systems have been developed for
classifying children’s behavior in the dental
environment. The knowledge of these systems holds
more than academic interest and can be an asset to
clinicians in two ways: it can assist in evaluating the
validity of current research, and it can provide a
systematic means for recording patients’
behaviours.
• When a clinician treats a child patient, the first issue
of concern is the child’s behavior. The clinician has
to classify the behavior (mentally at least) to help
guide the management approach.
• There is wide variation between classification
systems. One of the first was described by Wilson
(1933), who listed four classes of behavior— normal
or bold, bashful or timid, hysterical, and rebellious.
During the same year, sands wrote that children
were of five types—hypersensitive or alert, nervous,
fearful, physically unfit, and stubborn.
5
One of the most widely used systems was introduced by Frankl et al. in 1962. It is
referred to as the Frankl Behavioral Rating Scale.
• The Frankl classification method is often
considered the gold standard in clinical rating
scales.
• Its popularity as a research tool has stemmed
from 3 features.
• First, it is functional, as has been demonstrated
through repeated usage.
• Second, it is quantifiable. Since it has four
categorizations, numerical values can be assigned
to the observed behavior.
• Finally, it is reliable. A high level of agreement
among observers can be obtained. In fact, many
investigations using this tool have shown the level
of agreement to be 85% or higher—a very
acceptable level in this type of research. These are
the criteria for a measurement tool that are
necessary for a successful investigation. 6
• Wright in 1975 suggested that a symbol be added to this
rating scale, permitting the dentist to record a behaviour
base at the inception of dental treatment and to keep a
progressive record of the child’s behaviour.
• Wright (1975) gave the symbols to Frankl’s four types of
behaviour. They also gave a right sided arrow mark (→)
indicating the change in behaviour in the dental operatory
(due to fear or behaviour guidance)
7
8
Wright’s Classification (1975)
1. Cooperative behavior
2. Lacking cooperative behavior
3. Potentially cooperative behaviour( 5 subtypes )
• Incorrigible/uncontrolled behaviour: This is typically presented by 3–4 years old children at their first dental visit
or by older children at the time of injection. There is loud crying, kicking, and temper tantrums.
• Defiant/obstinate behaviour: This child has been termed as “spoiled kid” by Lampshire in 1970. He controls his
behavior in a sense by challenging the authority of the dentist. Typical responses are “I do not want my teeth
fixed” or “you cannot make me open my mouth.” These children have potentially severe emotional problems
that are manifested at home, school, and other areas of life.
• Timid behaviour: Often expressed by young children, particularly at the initial dental appointment. It is a result
of child’s anxiety about the dental experience and how he is expected to perform in the office. The child’s
anxiety may prevent him from listening attentively to the dentist, so instruction must be given slowly, quietly,
and repeated when necessary. Once the child gains confidence in the dentist, he can become excellent patient.
9
• Tense cooperative- borderline behaviour: They are extremely tensed; body language is different;
tremor in voice; sweating palms, hands. They can be cooperative if behaviour is managed well.
• Whining behaviour- The child with this type of behaviour can be extremely frustrating to treat. He
allows treatment, but he whines throughout the entire procedure.
4. Stoic behaviour- is a type of behaviour commonly mistaken to be a part of potentially
cooperative group. The child is generally cooperative, sits quietly, and accepts all dental
treatment including the injection without protest or any sign of discomfort. This behavior is
characteristic of children who have been physically abused.
10
Pinkham’s Classification-
• Category I: Emotionally compromised child
• Category II: Shy, introvert child
• Category III: Frightened child
• Category IV: Child who is adverse to authority
11
Lampshire’s
classification
(1970)
12
Pedodontic Treatment Triangle
• Conventional Model-
Patient-doctor relation in adults is linear, but in
pedodontics, the relation is triangular. This is
because in pedodontics, the parent and the child
both are involved and child is at the apex of triangle
as he is the focus of attention. This was first
elaborated best in the pediatric dentistry treatment
triangle given by Wright in 1975. The arrows
indicated that the communication is not only limited
to the benefit of the child but is reciprocal in nature.
13
Modified Model
• As community has become a major
part of all components of environment;
therefore, recently, a new parameter
has also been added, that is, society.
• This depiction looked complete with
the fact that the communication is
reciprocal and society came into the
center of the triangle indicating that
management methods acceptable to
society and the litigiousness of society
are important factors influencing
treatment modalities
14
• An authoritative or over indulgent
parent always tries to interfere in
the conversation between the
dentist and the child by answering
on behalf of the child.
• As a consequence, there is more
interaction between the parent
and the dentist hence the
equilateral triangle is replaced by
isosceles triangle .
15
• If the parent is negligent, then the conversation between the parent
and the dentist may not be reciprocal effectively; hence, right-angled
triangle replaces the normal equilateral triangle.
16
Pediatric Dentistry Treatment Model
• Padmanabhan et al. have proposed a new model based on the
pedodontic triangle and have termed it pediatric dentistry treatment
model.It presents the former triangle as a square which has the pediatric
dentist, pediatrician, family and society playing important roles and
definitely the child patient is the center of attention.
• Pediatric dentistry is an amalgamation of all the branches of dentistry and
most of its components have been either derived from or associated with
other dentistry branches, but the four principles that stand out in this
specialty are prevention, risk assessment and management, child
psychology and behavior management.
17
Factors which affect child’s behavior at the dental office
Under control of the dentist Out of control of the dentist Under the control of parents
Effect of dental office environment. Growth & Development Home environment
Effect of dentist’s activity & attitude Nutritional factors Family development & peer
influence
Dentist’s attire Past dental experiences Maternal behavior
Presence/Absence of parents in the
operatory
genetics
Presence of an older sibling School environment
Socioeconomic status
18
Dental Office Environment-
Bohuslov (1970) stated that psychological preparation of the child is based on the physical environment. Since the
child may enter the dental office with some fear, the first objective of the dentist should be to put the child at his
ease and make him realize that his experience is not unusual.
Finn summarized the following factors related to the dental office which influence child’s behaviour:
 Waiting room should be made in respect to home environment
 Make the reception room comfortable, so that the room is not foreign to them
 Have library with books for children of all ages
 Simple but sturdy toys must be kept to amuse very small children
 A handy record player with well-chosen records will provide comfort for a frightened child
 Appointment cards and announcements should be made attractive to children
 A sketch of some cartoon on card helps
 Operating room may be made more appealing to the child if a few pictures on the wall are suggestive of child at
play. A portrait of a carefree and laughing child is good
 Have an assistant skilled in making animals object out of cotton rolls
 Try to avoid the child patient, seeing anybody expressing in pain or sight of blood on others
19
Effect of dentist’s activity and attitudes
• The dentist should form a good impression on the child.
• The dentist should avoid jerky and quick movements and should be fluent
in his words and actions.
• Jenks (1964) has described 6 categories of activities by which the dentist
can enhance co-operation in children.
A) Data gathering and observation-
This involves collecting the type of information about a child and his parents
that can be obtained by a formal or informal office interview or by a written
questionnaire . Observation includes noting the behavior of the child as he
steps into the dental office during history taking and while the dental
procedure is being carried out.
20
B) Structuring- Refers to establishing certain guidelines of behaviour set by
the dentist and his team to the child so that the child knows what to expect
and how to react.
C) Externalization- It is the process by which child’s attention is focused away
from the sensations associated with the dental treatment . There are 2
components of externalization- Distraction, involvement
The objective is to interest and involve the child, but at the same time not to
let him into verbal or motor discharges, which might interfere with the
necessary procedure.
D) Empathy and support- Empathy is the capacity to understand and to
experience the feelings of another without losing one’s own objectivity .
Dentist must have the sensitivity and capacity to respond to the child’s
feelings.
E) Flexible authority- This includes compromises made by the dentist to meet
the needs of the particular patient.
F) Education and training 21
Effect of dentist’s attire
• If a child has previously
experienced a stressful situation ,
which includes the presence of
someone in white attire such as a
physician , the mere presence of a
white clothed individual would be
sufficient to evoke a negative
behaviour.
22
Presence of an older sibling
• An older sibling serves as a role model in a dental situation.
Presence of an older sibling has-
• Little effect on behavior of a 3 yr. old patient.
• No effect in case of 5 yr. old patients
• Most noticeable effect among 4 yr. olds
23
• Medical History- When studying a child’s medical experience, it is the emotional quality of past visits rather than
the number of visits to the physician that is significant. If the patient views a physician favourably, then the child is
likely to have less apprehension when visiting the dentist. Fears can thus be transferred from one situation to
another.
• Maternal Anxiety -In past years, it has been customary for mothers more often than fathers to accompany
children on a visit to the dentist; therefore, maternal anxiety was considered important. Highly anxious mother
had a negative influence on the child.
• Family and Peer Influence- Socioeconomic status of the family directly affects child’s attitude toward the values of
the dental health process. Those of low socioeconomic class, below average education, have a tendency to attend
dental needs when symptom dictates. These families harbour anxiety from dental treatment and these children
take on these fear and tend to be less cooperative. On the other hand if financial and educational means are
ample, families value good dental health easily established in preventive program.
24
Growth and Development-
A child’s chronological age plays a significant role in growth and developmental patterns. Younger the child, more atypical
will be the response. The intellectual age of 3 years signifies a maturational readiness to accept dental treatment.
Personal Factors-
Temperament and general fearfulness are some of the personal characters which are known to influence the behavior of the
child.
Environmental Factors-
 Toxic stress is the “result of strong, frequent, or prolonged activation of the body’s stress response systems in the absence
of the buffering protection of a supportive adult relationship. "This type of stress may be a result of child abuse and
neglect, exposure to violence, poverty, or maternal depression. Exposure can begin prenatally and can result in lasting
changes to the neural architecture, resulting in persistent developmental and physiologic harm and increasing risks for
lifelong chronic diseases.
 Evidence suggests individual differences are present in physiologic reactivity to stress, as measured by the amount of
corticotropin hormone released in stressful situations. Some children, dubbed dandelion children, are low reactors and
exhibit little physiologic change when presented with toxic stress, but other children, dubbed orchid children, exhibit
extreme physiologic changes (i.e., high reactors).
 Various environmental factors like age of the child, socioeconomic status, family situation, frequent exposure to invasive
medical care, past experience of operative dental care, etc. have been identified to influence the child’s behaviour.
However, parental dental fear has been noted to be the most influencing factor amongst all environmental factors.
 Klingberg (2007) observed cooperative children were fearful and uncooperative children were non-fearful. This indicated
that the children with behaviour management issues need not always be fearful. 25
Parenting styles & child behaviour
Baumrind defined following specific parenting styles—
• Positive behavior has been associated with
children of authoritative parents compared
with children of authoritarian and permissive
parents.
• Aminabadi et al. found a positive correlation
between authoritative parenting style and
positive child behavior and a correlation
between permissive parenting and negative
behaviors.
• Krikken et al. did not find an impact on child
behavior and anxiety associated with
parenting style, although for one group of
children, they did find increased anxiety with
authoritarian parenting style.
26
Cultural Influence on Parenting Style-
• Parenting styles and practices hold psychological and cultural meanings and vary between cultures.
For example, parental harshness (hostile behavior and/or physical punishment) carries a message of
care and concern within a culture valuing strict behavior controls and high expectations for children’s
behavior. However, in a less strict culture holding lower expectations for children’s behavior, it
carries a message of unsympathetic criticism (Ho et al. 2008). It was initially suggested that
Authoritative parenting likely would result in good psychosocial outcomes for children from all
ethnic and cultural groups.
• Some studies, however, have found better outcomes associated with the Authoritarian parenting
style, depending on family context and culture (Deater-Deckard et al. 1996; Ho et al. 2008).
• No investigation in any culture has reported consistent positive social outcomes for children of any
age with the Permissive or Neglectful parenting styles; this may be due to lack of rules and limits
upon the child’s conduct, which communicate which child behaviors are desired and expected and
which actions are unacceptable.
• Sociologists and educators have noted an increase in the Permissive parenting type in many
countries, including the United States (Long 2004).
27
• In traditional parenting models (Authoritarian, Authoritative), the adult
determines, communicates, clarifies, and enforces rules for the child.
In families with the Permissive parenting style, children question adult
authority and a “the child should feel good” ethos permeates family
life and parent decisions. Permissive parents are generally well-
intentioned, want to be nice, and would like their children to be happy
doing what they want to do. In some cases, the Permissive parent
attempts to become a friend to their child, abrogating the traditional
parental role of socialization.
• The term “helicopter parent” is employed in the popular lexicon to
describe a parent who is attentive, hovering, and available to rescue
their child from the consequences of any poor decisions or actions
(Cline and Fay 1990). Today’s ever-present cell phones have made it
inexpensive and simple for parents to stay connected to their child,
even when physically separated. It is theorized that the extension of
the usual time period of parent-child close connection may prolong
the child and young adult’s dependence upon parent and family
resources.
• There is no single “best” parenting style universal to all children. It is
believed that a child’s internal state of fear, arousal, and anxiety is
integral to their receptiveness to social learning; the best child
outcomes appear to result when a parent’s style is in harmony with
the child’s temperament.
28
Child Influence on the Parent
• The parent-child relationship is reciprocal, with each influencing the other’s thoughts, feelings, and behavior.
Parents and children develop a long history of interaction; each acquires a set of expectations concerning the
other’s behavior and establishes a method of interpreting the other’s reactions.
• Disruptive behavior in a toddler holds less consequence, risk to the child, and threat to the parent than
disruptive behavior in a teenager. Parenting affects children’s behavior most strongly during early childhood
(Slagt et al. 2012) while problematic adolescent behavior strongly affects parenting (Reitz et al. 2006). Parental
sense of competence is defined as a parent’s opinion of her ability to positively influence the behavior and
development of her child (Coleman and Karraker 1998).
• Social relations theory views children as active agents in their interactions with parents and assumes that
disagreements, conflicts and changes occur frequently. It is developmentally normal for children to resist some
of the socialization demands of their parents (Goh and Kuczynski 2009). A parent’s philosophy of parenting
(style) and behaviors (parenting practices) will determine the degree of parent accommodation and submission
to the natural resistance of the child.
• It has been observed that a child’s status and power is higher in single-child homes.
29
Application in Clinical Dental Practice-
• The dentist and staff should continually monitor the ambient emotional tone in the office and quickly intervene
in cases of negative emotional expression by parents. A parent who verbally or nonverbally expresses the stress
of a bad day is not emotionally available to help his child and may unintentionally sabotage that child’s dental
appointment.
• If the dentist or staff member’s sincere and respectful attempt to redirect the parent to the intended positive
purpose of the dental appointment is unsuccessful, the parent should be offered the opportunity to reschedule
at a time when they are more in control.
Sibling Influences-
Throughout life, the sibling relationship may be cooperative, ambivalent, or antagonistic. The child grows and
develops within a dynamic and variable family context across time. Multiple studies have confirmed that families
differentially distribute such resources as parental time, attention, money, nurturance, and love among the
children in a family. Parents tend to concentrate resources on some children and not on others.
Parent resource inequity between siblings has been examined based on birth order, child gender, sibling gender,
birth spacing, and birth intention (wanted versus unwanted pregnancy). Unintended children have been found to
receive fewer parent resources than intended siblings (Barber and East 2009).
Unwanted children are more likely to receive critical, punitive, abusive, and/or neglectful parenting (Barber et al.
1999). Inequitable treatment by parents has been found to have significant long-term negative effects on the
adjustment and self-esteem of the slighted child. (McGuire et al. 1995; Volling and Elins, 1998).
30
• Arrival of an infant has been found to adversely affect mother-to-older-sibling
interactions with decreased maternal attention, positive affection, and
attachment security, and often results in confrontations with the older child. It
is theorized that increased behavior problems of the older child are mediated
through changes in the mother-child relationship, particularly through
increases in the mother’s use of physical discipline (Volling 2005).
• It is important for the dentist to recognize the disruption and stress caused by
new sibling(s) in the home and to realize that the transition of a child to the
role of “big brother or big sister” comes at the cost of diminished parental
attention. The child patient may show signs of stress in their new role and
behave in a negative way to capture their parent’s attention. The goal should
be to keep the focus and nurturing of the dental team directed toward the
child patient, rather than on the newest family member and parent. The child
patient can be invited to introduce his new sibling to the dentist or staff
member. Examples of child-focused responses are: “It is nice to meet your
new sister, but today, you are the special one!” and “This is a very lucky baby
to have you for their own big brother!” 31
Maternal influence on child’s dental behaviour-
• While both the father and mother play important roles in their children's
psychologic development , emphasis has usually been placed on the role of
the mother. This is because mothers generally have more contact with their
children than do fathers.
• Maternal influences on children's mental, physical, and emotional
development begin even before birth. It is well known that a mother's
nutritional status as well as the state of physical health can affect the
neurologic and somatic development of the foetus.
• The expectant mother’s emotional state has also been correlated with
certain postnatal behavioural patterns of the child.
• It is believed that the foetus may be influenced by changes in the mother's
neurohormonal system, which are transmitted through the placenta.
Montagu has emphasized the importance of the prenatal environment on
the later development of the child. He cites a study linking stimulation of the
foetus to postnatal feeding difficulty, and another study in which mothers
who underwent severe emotional stress during pregnancy tended to have
excessively active, irritable infants.
32
MATERNAL INFLUENCE ON PERSONALITY DEVELOPMENT-
• While children's behaviour can influence the behaviour of mothers, research into parent-child
relationships usually views the parent as the independent variable and the child as the
dependent one. Bell has termed this relationship "one-tailed," since parental characteristics are
viewed as having a unilateral influence on those developing in the child.
• Bayley and Schaefer indicate that most of the relevant mother-child relationships fall into two
broad çategories: autonomy vs control and
hostility vs love .
• Maternal attitudes and behaviors have been described and rated in relation to these two
categories, and Schaefer has developed a model in which gradations of maternal behavior are
arranged sequentially around the two reference pairings of autonomy vs control and hostility vs
love.
33
o The behaviour of mothers who participated in the
Berkeley Growth Study was rated according to the
attitudes depicted in the Schaefer model. The
mothers' attitudes were then correlated with the
behaviour of their sons. While there were some
differences associated with the children's ages and
other variable it was found that loving mothers
tended to have calm, happy sons, while hostile
mothers had sons who were excitable and
unhappy.
In general, mothers who allowed autonomy and
who expressed affection had sons who were
friendly, cooperative, and attentive.
Conversely, punitive mothers and those who
ignored their children did not have sons who
exhibited these positive behavioural characteristics.
The dental implications of the effects of maternal
attitudes-in moulding children's personalities are
apparent, as the friendly, cooperative child will
probably also exhibit these traits in the dental
office.
34
Love
EFFECT OF THE MOTHER'S PRESENCE IN THE OPERATORY-
• Many dentists prefer to exclude parents from the operatory. This attitude was confirmed in a
study by Roder and co-workers, who sent questionnaires to 910 dentists to determine whether
they preferred to treat children with the parent’s presence or absence. Nearly 70% of the dentists
responded that they preferred to treat children with the parents absent; only 40 preferred the
parents present.
• It was concluded that the presence of the mother during the treatment of a well-behaved child
does not increase the dentist's anxiety; thus, anxiety is probably not the reason the majority of
dentists prefer to exclude parents from the operatory, it is quite probable that dentists generally
prefer to have parents absent from the operating room while children are being treated because
children behave satisfactorily without a parent present.
35
Maternal attitude
36
37
Effect of the Parental Presence in the Operatory-
• It is quite probable that dentists generally prefer to have parents absent from the operating room while
children are being treated because most children behave satisfactorily without parental presence. In fact,
as children get older and develop emotional independence, they themselves prefer they have their parent
remain in the waiting room.
• If a child exhibits uncooperative behaviour, the presence of the parent will sometimes lend support to this
type of behaviour and it can also limit the range of behaviour control techniques of the dentist. Parent
should not, however, be routinely excluded from the operatory as there are certain occasions when their
presence is desirable and actually enhances positive behaviour on the part of child
• Frankl found that children in age group of 42–49 months are benefited from mother’s presence.
• Young children are more prone to a number of fears, like fear of unknown, and hence exhibit anxiety
during short-term separation and the degree of response is affected by length of separations.
38
Crying in the dental office-
• It is not uncommon to witness a child who is crying while in the dental
chair. All crying, however, should not communicate the same message
to the dentist.
Elsbach has described four types of children's cries:
• Obstinate cry- child who ""throws a temper tantrum" to thwart dental
treatment exhibits the obstinate cry. This cry is loud, high-pitched, and
has been characterized as a siren-like wail. This form of belligerence
represents the child's external response to his anxiety in the dental
situation.
• Frightened cry- The frightened cry is usually accompanied by a torrent
of tears and convulsive, breath-catching sobs. The child emitting this
type of cry has been overwhelmed by the situation. This child cannot
be managed with the same techniques that would be used for the
belligerent child. It is the dentist's responsibility to instill confidence in
the frightened child by providing a series of carefully structured dental
experiences that will allow the child to cope. 39
• Hurt cry- The hurt cry may be loud; more frequently, however, it
is accompanied by a small whimper. The first indication that the
child is in discomfort may be a single tear welling from the corner
of the eye and running down the child's cheek. The hurt cry is
easily identified because the child will state, either voluntarily or
when asked, that he is being hurt. Some children may be in pain
but may control their physical activity so that the dentist is
unaware of a problem.
• Compensatory cry- compensatory cry as "not really a cry at all. It
is a sound the child makes to drown out the noise of the dentist's
drill.*"* Usually the sound is a droning monotone. While it may
be annoying to the dentist, it is the child's way of coping with
what he considers unpleasant auditory stimuli. The dentist
should recognize the compensatory as a strategy the child has
developed to cope with the anxiety that he is experiencing. It is a
successful coping stratagem, and therefore the dentist should
make no attempt to stop it.
40
Parental Behaviour in the Dental Office -
• Parental behaviour in the dental office also plays an important role in child management. Parents must
understand that once the child is in the office, the dentist knows how to prepare the child emotionally for
the necessary treatment. If a parent is invited into the treatment room, he must assume the role of a passive
guest and either sit or stand away from the chair.
Some instructions that should be told to the parents are:
• Tell the parents not to voice their own personal fears in front of the child
• Tell the parents never to use dentistry as a threat of punishment
• Parents should familiarize their children with dentistry by taking the child to the dentist to
become accustomed to the dental office and the dentist.
• Explain to the parent that an occasional display of courage on his part in dental matters will build
courage in the child
41
• Consult the parent about the home environment and the importance of moderate
parental attitudes in building well-adjusted child
• Parents should stress the value of regular dental care, not only in preserving the teeth
but also in formation of good dental patients
• Discourage parents from bribing their child to go to the dentist
• The parent should be instructed never to shame or ridicule to overcome the fear
• The parent should not promise the child what the dentist is or is not going to do
• Several days before the appointment, the parent should be instructed to convey to the
child in a casual manner that they have been invited to visit the dentist.
42
Parent–Child Separation
• Wright noted that excluding the parent from the operating room could contribute in controlling the
child’s positive behavior. Most dentists probably are more relaxed and comfortable when parent
remains in the reception area and their action has positive effect on children’s behavior.
• Some factors which influence the dentist not to include parent in the operatory are:
 Parents often repeat orders, creating an annoyance for both dentist and child patient
 Parents impose orders, becoming a barrier to the development of rapport between the dentist and
child
 Dentist is unable to use voice intonation in the presence of the parent because he may be offended
 Child divides attention between parent and dentist
 Dentist’s attention is divided between parent and child.
43
Demographics-
 Most studies find that negative behavior in the dental office is most intense in younger children and
decreases as children grow older. Dental anxiety also decreases as the child grows older, as does needle
phobia, most likely due to maturing communication and coping skills. However, it is important to assess the
patient’s degree of psychological development because that may be more important than chronologic age
when predicting disruptive behavior.
 The role of gender in dental anxiety and misbehavior is not as clear. The majority of studies found increased
anxiety in females, particularly after children pass early school age,while others found no difference.
Klingberg and Broberg concluded in a 2007 review of the literature that a clear trend exists, with girls being
both more dentally anxious and exhibiting more behavior management problems, which was in contrast
with an early 1982 review where no clear difference in gender was found. This may be in part due to
increased willingness for females to verbalize fears because of cultural norms for gender.
44
ROLE OF DENTIST IN CHILD’S BEHAVIOUR-
Appearance of dental office:
 Make one corner of waiting room for the child
only where he can play, sit, and read
 Record player playing soothing music to ease fear
 Appointment cards to be appealing to the child
 Operating room should be appealing to the child
having cartoon and pictures on walls
 Time and length of appointment: Better to have
morning appointments and also prevent
appointments during the child’s sleeping, playing,
or eating time. Duration should be short.
45
• Dentist’s skill and speed: Dentist should be skilled or he will lose the child’s
confidence
• Attention to patient: Treat the patient as he is the only one seen during that day.
Never leave him alone in chair and do not change rooms as all this increases
anxiety
• Dentist’s conversation: Keep talking to the child to gain his confidence. Use
simple words and answer all questions.
• Use of simple words: Do not use fear promoting words like needle, injection
• Reasonableness of dentist: Be realistic and reasonable. Try to put yourself in the
child’s place and see why he behaves in this particular way.
• Use of admiration, subtle flattering, praise, and reward: Enforces the behavior
for future
• Self-control of dentist: Dentist should never lose his temper. It is a mark of
defeat and indication to child that he has succeeded in undermining your dignity
46
References
• Behavior Management in Dentistry for Children , Edited by Gerald Z. Wright
Ari Kupietzky
• Ripa LW, Barenie JT. Management of Dental Behavior in Children. 1979.
• Casamassimo PS, Fields HW, McTigue DJ, Nowak A. Pediatric Dentistry -
,Infancy through Adolescence,5. Elsevier Health Sciences; 2012.
• Dean JA. McDonald and Avery’s Dentistry for the Child and Adolescent - E-
Book. Elsevier Health Sciences; 2021.
• Textbook of Pediatric Dentistry by Dr Shobha Tandon, Third Edition.
• Marwah N. Textbook of Pediatric Dentistry. JP Medical Ltd; 2018.
• Arathi Rao, Principles & practice in Pedodotics
47
Thankyou
48

More Related Content

Similar to Factors Affecting child behavior in Pediatric Dentistry

non pharmacological behavior management techniques
non pharmacological behavior management techniquesnon pharmacological behavior management techniques
non pharmacological behavior management techniques
Dr Anukriti sharma
 
Behavioural sciences and its application to pedodontics
Behavioural sciences and its application to pedodonticsBehavioural sciences and its application to pedodontics
Behavioural sciences and its application to pedodontics
Narsinhbhai Patel Dental College and Hospital
 
behaviour management -non pharmacological.pptx
behaviour management -non pharmacological.pptxbehaviour management -non pharmacological.pptx
behaviour management -non pharmacological.pptx
dptpedosaids
 
Non pharmacological behavior management in pediatric dentistry
Non pharmacological behavior management in pediatric dentistryNon pharmacological behavior management in pediatric dentistry
Non pharmacological behavior management in pediatric dentistry
Pratima Kolekar
 
Learning, Motivation and Applications
Learning, Motivation and ApplicationsLearning, Motivation and Applications
Learning, Motivation and Applications
Jacey Mitchell
 
behavioural sciences & Patient motivation
 behavioural sciences & Patient motivation behavioural sciences & Patient motivation
behavioural sciences & Patient motivation
Aditi Singh
 
Pedodontics I lecture 04
Pedodontics I lecture 04Pedodontics I lecture 04
Pedodontics I lecture 04
Lama K Banna
 
Pediatric Behavior Management
Pediatric Behavior ManagementPediatric Behavior Management
Pediatric Behavior Management
Jacey Mitchell
 
Pedia psychology
Pedia psychologyPedia psychology
Pedia psychology
IAU Dent
 
Behaviour management guidelines
Behaviour management guidelinesBehaviour management guidelines
Behaviour management guidelines
Shahid Mitha
 
Handicapped Children PAEDIATRIC DENTISTRY
Handicapped Children PAEDIATRIC DENTISTRYHandicapped Children PAEDIATRIC DENTISTRY
Handicapped Children PAEDIATRIC DENTISTRY
Jamil Kifayatullah
 
Behavioural Management in Pediatric Dentistry
Behavioural Management in Pediatric DentistryBehavioural Management in Pediatric Dentistry
Behavioural Management in Pediatric Dentistry
SwalihaAlthaf
 
Transforming Care: Share and Learn Webinar – 29 March 2018
Transforming Care: Share and Learn Webinar – 29 March 2018Transforming Care: Share and Learn Webinar – 29 March 2018
Transforming Care: Share and Learn Webinar – 29 March 2018
NHS England
 
Patient management 1 /certified fixed orthodontic courses by Indian dental ac...
Patient management 1 /certified fixed orthodontic courses by Indian dental ac...Patient management 1 /certified fixed orthodontic courses by Indian dental ac...
Patient management 1 /certified fixed orthodontic courses by Indian dental ac...
Indian dental academy
 
Cochlear
CochlearCochlear
Cochlear
Neha Sharma
 
Sharing Learning and Best Practices Between Professionals Working with Young ...
Sharing Learning and Best Practices Between Professionals Working with Young ...Sharing Learning and Best Practices Between Professionals Working with Young ...
Sharing Learning and Best Practices Between Professionals Working with Young ...
BASPCAN
 
Dental home Pediatrics
Dental home Pediatrics Dental home Pediatrics
Dental home Pediatrics
AkshMinhas
 
Communication skills
 Communication skills Communication skills
Communication skills
Leena Ghag-Sakpal
 
Non Pharmacological Behavior Management.ppt
Non Pharmacological Behavior Management.pptNon Pharmacological Behavior Management.ppt
Non Pharmacological Behavior Management.ppt
malti19
 
Child behavior management TECHNIQUES
Child  behavior management TECHNIQUESChild  behavior management TECHNIQUES
Child behavior management TECHNIQUES
PAVAN KUMAR Sinsinwar
 

Similar to Factors Affecting child behavior in Pediatric Dentistry (20)

non pharmacological behavior management techniques
non pharmacological behavior management techniquesnon pharmacological behavior management techniques
non pharmacological behavior management techniques
 
Behavioural sciences and its application to pedodontics
Behavioural sciences and its application to pedodonticsBehavioural sciences and its application to pedodontics
Behavioural sciences and its application to pedodontics
 
behaviour management -non pharmacological.pptx
behaviour management -non pharmacological.pptxbehaviour management -non pharmacological.pptx
behaviour management -non pharmacological.pptx
 
Non pharmacological behavior management in pediatric dentistry
Non pharmacological behavior management in pediatric dentistryNon pharmacological behavior management in pediatric dentistry
Non pharmacological behavior management in pediatric dentistry
 
Learning, Motivation and Applications
Learning, Motivation and ApplicationsLearning, Motivation and Applications
Learning, Motivation and Applications
 
behavioural sciences & Patient motivation
 behavioural sciences & Patient motivation behavioural sciences & Patient motivation
behavioural sciences & Patient motivation
 
Pedodontics I lecture 04
Pedodontics I lecture 04Pedodontics I lecture 04
Pedodontics I lecture 04
 
Pediatric Behavior Management
Pediatric Behavior ManagementPediatric Behavior Management
Pediatric Behavior Management
 
Pedia psychology
Pedia psychologyPedia psychology
Pedia psychology
 
Behaviour management guidelines
Behaviour management guidelinesBehaviour management guidelines
Behaviour management guidelines
 
Handicapped Children PAEDIATRIC DENTISTRY
Handicapped Children PAEDIATRIC DENTISTRYHandicapped Children PAEDIATRIC DENTISTRY
Handicapped Children PAEDIATRIC DENTISTRY
 
Behavioural Management in Pediatric Dentistry
Behavioural Management in Pediatric DentistryBehavioural Management in Pediatric Dentistry
Behavioural Management in Pediatric Dentistry
 
Transforming Care: Share and Learn Webinar – 29 March 2018
Transforming Care: Share and Learn Webinar – 29 March 2018Transforming Care: Share and Learn Webinar – 29 March 2018
Transforming Care: Share and Learn Webinar – 29 March 2018
 
Patient management 1 /certified fixed orthodontic courses by Indian dental ac...
Patient management 1 /certified fixed orthodontic courses by Indian dental ac...Patient management 1 /certified fixed orthodontic courses by Indian dental ac...
Patient management 1 /certified fixed orthodontic courses by Indian dental ac...
 
Cochlear
CochlearCochlear
Cochlear
 
Sharing Learning and Best Practices Between Professionals Working with Young ...
Sharing Learning and Best Practices Between Professionals Working with Young ...Sharing Learning and Best Practices Between Professionals Working with Young ...
Sharing Learning and Best Practices Between Professionals Working with Young ...
 
Dental home Pediatrics
Dental home Pediatrics Dental home Pediatrics
Dental home Pediatrics
 
Communication skills
 Communication skills Communication skills
Communication skills
 
Non Pharmacological Behavior Management.ppt
Non Pharmacological Behavior Management.pptNon Pharmacological Behavior Management.ppt
Non Pharmacological Behavior Management.ppt
 
Child behavior management TECHNIQUES
Child  behavior management TECHNIQUESChild  behavior management TECHNIQUES
Child behavior management TECHNIQUES
 

Recently uploaded

SENSORY NEEDS B.SC. NURSING SEMESTER II.
SENSORY NEEDS B.SC. NURSING SEMESTER II.SENSORY NEEDS B.SC. NURSING SEMESTER II.
SENSORY NEEDS B.SC. NURSING SEMESTER II.
KULDEEP VYAS
 
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdfMedical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
Jim Jacob Roy
 
The Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of RespirationThe Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of Respiration
MedicoseAcademics
 
Nano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory projectNano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory project
SIVAVINAYAKPK
 
Skin Diseases That Happen During Summer.
 Skin Diseases That Happen During Summer. Skin Diseases That Happen During Summer.
Skin Diseases That Happen During Summer.
Gokuldas Hospital
 
pharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdfpharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdf
KerlynIgnacio
 
Hemodialysis: Chapter 5, Dialyzers Overview - Dr.Gawad
Hemodialysis: Chapter 5, Dialyzers Overview - Dr.GawadHemodialysis: Chapter 5, Dialyzers Overview - Dr.Gawad
Hemodialysis: Chapter 5, Dialyzers Overview - Dr.Gawad
NephroTube - Dr.Gawad
 
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga
 
Pharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and AntagonistPharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and Antagonist
Dr. Nikhilkumar Sakle
 
DECLARATION OF HELSINKI - History and principles
DECLARATION OF HELSINKI - History and principlesDECLARATION OF HELSINKI - History and principles
DECLARATION OF HELSINKI - History and principles
anaghabharat01
 
MRI for Surgeons introduction and basics
MRI for Surgeons  introduction and basicsMRI for Surgeons  introduction and basics
MRI for Surgeons introduction and basics
rohitsharma19711
 
How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.
Gokuldas Hospital
 
Tele Optometry (kunj'sppt) / Basics of tele optometry.
Tele Optometry (kunj'sppt) / Basics of tele optometry.Tele Optometry (kunj'sppt) / Basics of tele optometry.
Tele Optometry (kunj'sppt) / Basics of tele optometry.
Kunj Vihari
 
Case presentation On Urinary tract infection
Case presentation On Urinary tract infectionCase presentation On Urinary tract infection
Case presentation On Urinary tract infection
KarthyAks1
 
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdfOphthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
MuhammadMuneer49
 
Ageing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public HealthAgeing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public Health
phuakl
 
CBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdfCBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdf
suvadeepdas911
 
What are the different types of Dental implants.
What are the different types of Dental implants.What are the different types of Dental implants.
What are the different types of Dental implants.
Gokuldas Hospital
 
Breast cancer: Post menopausal endocrine therapy
Breast cancer: Post menopausal endocrine therapyBreast cancer: Post menopausal endocrine therapy
Breast cancer: Post menopausal endocrine therapy
Dr. Sumit KUMAR
 
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
MuskanShingari
 

Recently uploaded (20)

SENSORY NEEDS B.SC. NURSING SEMESTER II.
SENSORY NEEDS B.SC. NURSING SEMESTER II.SENSORY NEEDS B.SC. NURSING SEMESTER II.
SENSORY NEEDS B.SC. NURSING SEMESTER II.
 
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdfMedical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
 
The Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of RespirationThe Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of Respiration
 
Nano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory projectNano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory project
 
Skin Diseases That Happen During Summer.
 Skin Diseases That Happen During Summer. Skin Diseases That Happen During Summer.
Skin Diseases That Happen During Summer.
 
pharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdfpharmacology for dummies free pdf download.pdf
pharmacology for dummies free pdf download.pdf
 
Hemodialysis: Chapter 5, Dialyzers Overview - Dr.Gawad
Hemodialysis: Chapter 5, Dialyzers Overview - Dr.GawadHemodialysis: Chapter 5, Dialyzers Overview - Dr.Gawad
Hemodialysis: Chapter 5, Dialyzers Overview - Dr.Gawad
 
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
 
Pharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and AntagonistPharmacology of 5-hydroxytryptamine and Antagonist
Pharmacology of 5-hydroxytryptamine and Antagonist
 
DECLARATION OF HELSINKI - History and principles
DECLARATION OF HELSINKI - History and principlesDECLARATION OF HELSINKI - History and principles
DECLARATION OF HELSINKI - History and principles
 
MRI for Surgeons introduction and basics
MRI for Surgeons  introduction and basicsMRI for Surgeons  introduction and basics
MRI for Surgeons introduction and basics
 
How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.How to choose the best dermatologists in Indore.
How to choose the best dermatologists in Indore.
 
Tele Optometry (kunj'sppt) / Basics of tele optometry.
Tele Optometry (kunj'sppt) / Basics of tele optometry.Tele Optometry (kunj'sppt) / Basics of tele optometry.
Tele Optometry (kunj'sppt) / Basics of tele optometry.
 
Case presentation On Urinary tract infection
Case presentation On Urinary tract infectionCase presentation On Urinary tract infection
Case presentation On Urinary tract infection
 
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdfOphthalmic drugs latest. Xxxxxxzxxxxxx.pdf
Ophthalmic drugs latest. Xxxxxxzxxxxxx.pdf
 
Ageing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public HealthAgeing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public Health
 
CBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdfCBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdf
 
What are the different types of Dental implants.
What are the different types of Dental implants.What are the different types of Dental implants.
What are the different types of Dental implants.
 
Breast cancer: Post menopausal endocrine therapy
Breast cancer: Post menopausal endocrine therapyBreast cancer: Post menopausal endocrine therapy
Breast cancer: Post menopausal endocrine therapy
 
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
 

Factors Affecting child behavior in Pediatric Dentistry

  • 1. Child Behavior Dr Simran Vangani 2nd year PG Dept. of Pediatric & preventive Dentistry,MGDCH 1
  • 2. Introduction Successful dentistry for children depends not only upon the dentist's technical skills but also upon his ability to acquire and maintain a child's cooperation. Most children strive to be cooperative; in these instances, the dentist should support the child's behaviour. When a child is uncooperative, however, his behaviour must be altered and controlled. 2
  • 3. • Behaviour- is any activity that can be observed, recorded, and measured. It is an observable act or any change in the functioning of an organism. • Behavioral pedodontics- is the study of science that helps to understand development of fear, anxiety, anger, and associated acts as it applies to the child in the dental situation. • Behavior guidance- is a continuum of interaction involving the dentist, the dental team, the patient, and the parent directed toward communication and education “which ultimately builds trust and allays fear and anxiety” • 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 (Wright, 1975) • Behavior modification -is defined as the attempt to alter human behavior and emotion in a beneficial manner according to the laws of modern learning theory (Eysenck, 1964) • ™ Behaviour shaping is the procedure, which slowly develops behavior by reinforcing a successive approximation of the desired behavior until the desired behavior comes into being, for example, desensitization, tell–show–do (TSD), modeling, distraction, contingency management. 3
  • 4. Classification of child behavior in dental office- One of the cornerstones in practicing pediatric dentistry is the ability to guide children positively throughout their dental experience and encourage a positive dental attitude to improve their oral health. Assessment and management of children based on their behavior are the most important skills for a pediatric dentist. It is important for pediatric dentists to assess and evaluate psychological, personal traits, and behavioral responses of the child, as they play a major role in the management of dental anxiety and fear. Evaluation of the child’s behavior serves as an aid in directing individualized behavior guidance approach that facilitates dental treatment and provides a means for systematically recording behaviors for future appointments. 4
  • 5. • Numerous systems have been developed for classifying children’s behavior in the dental environment. The knowledge of these systems holds more than academic interest and can be an asset to clinicians in two ways: it can assist in evaluating the validity of current research, and it can provide a systematic means for recording patients’ behaviours. • When a clinician treats a child patient, the first issue of concern is the child’s behavior. The clinician has to classify the behavior (mentally at least) to help guide the management approach. • There is wide variation between classification systems. One of the first was described by Wilson (1933), who listed four classes of behavior— normal or bold, bashful or timid, hysterical, and rebellious. During the same year, sands wrote that children were of five types—hypersensitive or alert, nervous, fearful, physically unfit, and stubborn. 5
  • 6. One of the most widely used systems was introduced by Frankl et al. in 1962. It is referred to as the Frankl Behavioral Rating Scale. • The Frankl classification method is often considered the gold standard in clinical rating scales. • Its popularity as a research tool has stemmed from 3 features. • First, it is functional, as has been demonstrated through repeated usage. • Second, it is quantifiable. Since it has four categorizations, numerical values can be assigned to the observed behavior. • Finally, it is reliable. A high level of agreement among observers can be obtained. In fact, many investigations using this tool have shown the level of agreement to be 85% or higher—a very acceptable level in this type of research. These are the criteria for a measurement tool that are necessary for a successful investigation. 6
  • 7. • Wright in 1975 suggested that a symbol be added to this rating scale, permitting the dentist to record a behaviour base at the inception of dental treatment and to keep a progressive record of the child’s behaviour. • Wright (1975) gave the symbols to Frankl’s four types of behaviour. They also gave a right sided arrow mark (→) indicating the change in behaviour in the dental operatory (due to fear or behaviour guidance) 7
  • 8. 8
  • 9. Wright’s Classification (1975) 1. Cooperative behavior 2. Lacking cooperative behavior 3. Potentially cooperative behaviour( 5 subtypes ) • Incorrigible/uncontrolled behaviour: This is typically presented by 3–4 years old children at their first dental visit or by older children at the time of injection. There is loud crying, kicking, and temper tantrums. • Defiant/obstinate behaviour: This child has been termed as “spoiled kid” by Lampshire in 1970. He controls his behavior in a sense by challenging the authority of the dentist. Typical responses are “I do not want my teeth fixed” or “you cannot make me open my mouth.” These children have potentially severe emotional problems that are manifested at home, school, and other areas of life. • Timid behaviour: Often expressed by young children, particularly at the initial dental appointment. It is a result of child’s anxiety about the dental experience and how he is expected to perform in the office. The child’s anxiety may prevent him from listening attentively to the dentist, so instruction must be given slowly, quietly, and repeated when necessary. Once the child gains confidence in the dentist, he can become excellent patient. 9
  • 10. • Tense cooperative- borderline behaviour: They are extremely tensed; body language is different; tremor in voice; sweating palms, hands. They can be cooperative if behaviour is managed well. • Whining behaviour- The child with this type of behaviour can be extremely frustrating to treat. He allows treatment, but he whines throughout the entire procedure. 4. Stoic behaviour- is a type of behaviour commonly mistaken to be a part of potentially cooperative group. The child is generally cooperative, sits quietly, and accepts all dental treatment including the injection without protest or any sign of discomfort. This behavior is characteristic of children who have been physically abused. 10
  • 11. Pinkham’s Classification- • Category I: Emotionally compromised child • Category II: Shy, introvert child • Category III: Frightened child • Category IV: Child who is adverse to authority 11
  • 13. Pedodontic Treatment Triangle • Conventional Model- Patient-doctor relation in adults is linear, but in pedodontics, the relation is triangular. This is because in pedodontics, the parent and the child both are involved and child is at the apex of triangle as he is the focus of attention. This was first elaborated best in the pediatric dentistry treatment triangle given by Wright in 1975. The arrows indicated that the communication is not only limited to the benefit of the child but is reciprocal in nature. 13
  • 14. Modified Model • As community has become a major part of all components of environment; therefore, recently, a new parameter has also been added, that is, society. • This depiction looked complete with the fact that the communication is reciprocal and society came into the center of the triangle indicating that management methods acceptable to society and the litigiousness of society are important factors influencing treatment modalities 14
  • 15. • An authoritative or over indulgent parent always tries to interfere in the conversation between the dentist and the child by answering on behalf of the child. • As a consequence, there is more interaction between the parent and the dentist hence the equilateral triangle is replaced by isosceles triangle . 15
  • 16. • If the parent is negligent, then the conversation between the parent and the dentist may not be reciprocal effectively; hence, right-angled triangle replaces the normal equilateral triangle. 16
  • 17. Pediatric Dentistry Treatment Model • Padmanabhan et al. have proposed a new model based on the pedodontic triangle and have termed it pediatric dentistry treatment model.It presents the former triangle as a square which has the pediatric dentist, pediatrician, family and society playing important roles and definitely the child patient is the center of attention. • Pediatric dentistry is an amalgamation of all the branches of dentistry and most of its components have been either derived from or associated with other dentistry branches, but the four principles that stand out in this specialty are prevention, risk assessment and management, child psychology and behavior management. 17
  • 18. Factors which affect child’s behavior at the dental office Under control of the dentist Out of control of the dentist Under the control of parents Effect of dental office environment. Growth & Development Home environment Effect of dentist’s activity & attitude Nutritional factors Family development & peer influence Dentist’s attire Past dental experiences Maternal behavior Presence/Absence of parents in the operatory genetics Presence of an older sibling School environment Socioeconomic status 18
  • 19. Dental Office Environment- Bohuslov (1970) stated that psychological preparation of the child is based on the physical environment. Since the child may enter the dental office with some fear, the first objective of the dentist should be to put the child at his ease and make him realize that his experience is not unusual. Finn summarized the following factors related to the dental office which influence child’s behaviour:  Waiting room should be made in respect to home environment  Make the reception room comfortable, so that the room is not foreign to them  Have library with books for children of all ages  Simple but sturdy toys must be kept to amuse very small children  A handy record player with well-chosen records will provide comfort for a frightened child  Appointment cards and announcements should be made attractive to children  A sketch of some cartoon on card helps  Operating room may be made more appealing to the child if a few pictures on the wall are suggestive of child at play. A portrait of a carefree and laughing child is good  Have an assistant skilled in making animals object out of cotton rolls  Try to avoid the child patient, seeing anybody expressing in pain or sight of blood on others 19
  • 20. Effect of dentist’s activity and attitudes • The dentist should form a good impression on the child. • The dentist should avoid jerky and quick movements and should be fluent in his words and actions. • Jenks (1964) has described 6 categories of activities by which the dentist can enhance co-operation in children. A) Data gathering and observation- This involves collecting the type of information about a child and his parents that can be obtained by a formal or informal office interview or by a written questionnaire . Observation includes noting the behavior of the child as he steps into the dental office during history taking and while the dental procedure is being carried out. 20
  • 21. B) Structuring- Refers to establishing certain guidelines of behaviour set by the dentist and his team to the child so that the child knows what to expect and how to react. C) Externalization- It is the process by which child’s attention is focused away from the sensations associated with the dental treatment . There are 2 components of externalization- Distraction, involvement The objective is to interest and involve the child, but at the same time not to let him into verbal or motor discharges, which might interfere with the necessary procedure. D) Empathy and support- Empathy is the capacity to understand and to experience the feelings of another without losing one’s own objectivity . Dentist must have the sensitivity and capacity to respond to the child’s feelings. E) Flexible authority- This includes compromises made by the dentist to meet the needs of the particular patient. F) Education and training 21
  • 22. Effect of dentist’s attire • If a child has previously experienced a stressful situation , which includes the presence of someone in white attire such as a physician , the mere presence of a white clothed individual would be sufficient to evoke a negative behaviour. 22
  • 23. Presence of an older sibling • An older sibling serves as a role model in a dental situation. Presence of an older sibling has- • Little effect on behavior of a 3 yr. old patient. • No effect in case of 5 yr. old patients • Most noticeable effect among 4 yr. olds 23
  • 24. • Medical History- When studying a child’s medical experience, it is the emotional quality of past visits rather than the number of visits to the physician that is significant. If the patient views a physician favourably, then the child is likely to have less apprehension when visiting the dentist. Fears can thus be transferred from one situation to another. • Maternal Anxiety -In past years, it has been customary for mothers more often than fathers to accompany children on a visit to the dentist; therefore, maternal anxiety was considered important. Highly anxious mother had a negative influence on the child. • Family and Peer Influence- Socioeconomic status of the family directly affects child’s attitude toward the values of the dental health process. Those of low socioeconomic class, below average education, have a tendency to attend dental needs when symptom dictates. These families harbour anxiety from dental treatment and these children take on these fear and tend to be less cooperative. On the other hand if financial and educational means are ample, families value good dental health easily established in preventive program. 24
  • 25. Growth and Development- A child’s chronological age plays a significant role in growth and developmental patterns. Younger the child, more atypical will be the response. The intellectual age of 3 years signifies a maturational readiness to accept dental treatment. Personal Factors- Temperament and general fearfulness are some of the personal characters which are known to influence the behavior of the child. Environmental Factors-  Toxic stress is the “result of strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive adult relationship. "This type of stress may be a result of child abuse and neglect, exposure to violence, poverty, or maternal depression. Exposure can begin prenatally and can result in lasting changes to the neural architecture, resulting in persistent developmental and physiologic harm and increasing risks for lifelong chronic diseases.  Evidence suggests individual differences are present in physiologic reactivity to stress, as measured by the amount of corticotropin hormone released in stressful situations. Some children, dubbed dandelion children, are low reactors and exhibit little physiologic change when presented with toxic stress, but other children, dubbed orchid children, exhibit extreme physiologic changes (i.e., high reactors).  Various environmental factors like age of the child, socioeconomic status, family situation, frequent exposure to invasive medical care, past experience of operative dental care, etc. have been identified to influence the child’s behaviour. However, parental dental fear has been noted to be the most influencing factor amongst all environmental factors.  Klingberg (2007) observed cooperative children were fearful and uncooperative children were non-fearful. This indicated that the children with behaviour management issues need not always be fearful. 25
  • 26. Parenting styles & child behaviour Baumrind defined following specific parenting styles— • Positive behavior has been associated with children of authoritative parents compared with children of authoritarian and permissive parents. • Aminabadi et al. found a positive correlation between authoritative parenting style and positive child behavior and a correlation between permissive parenting and negative behaviors. • Krikken et al. did not find an impact on child behavior and anxiety associated with parenting style, although for one group of children, they did find increased anxiety with authoritarian parenting style. 26
  • 27. Cultural Influence on Parenting Style- • Parenting styles and practices hold psychological and cultural meanings and vary between cultures. For example, parental harshness (hostile behavior and/or physical punishment) carries a message of care and concern within a culture valuing strict behavior controls and high expectations for children’s behavior. However, in a less strict culture holding lower expectations for children’s behavior, it carries a message of unsympathetic criticism (Ho et al. 2008). It was initially suggested that Authoritative parenting likely would result in good psychosocial outcomes for children from all ethnic and cultural groups. • Some studies, however, have found better outcomes associated with the Authoritarian parenting style, depending on family context and culture (Deater-Deckard et al. 1996; Ho et al. 2008). • No investigation in any culture has reported consistent positive social outcomes for children of any age with the Permissive or Neglectful parenting styles; this may be due to lack of rules and limits upon the child’s conduct, which communicate which child behaviors are desired and expected and which actions are unacceptable. • Sociologists and educators have noted an increase in the Permissive parenting type in many countries, including the United States (Long 2004). 27
  • 28. • In traditional parenting models (Authoritarian, Authoritative), the adult determines, communicates, clarifies, and enforces rules for the child. In families with the Permissive parenting style, children question adult authority and a “the child should feel good” ethos permeates family life and parent decisions. Permissive parents are generally well- intentioned, want to be nice, and would like their children to be happy doing what they want to do. In some cases, the Permissive parent attempts to become a friend to their child, abrogating the traditional parental role of socialization. • The term “helicopter parent” is employed in the popular lexicon to describe a parent who is attentive, hovering, and available to rescue their child from the consequences of any poor decisions or actions (Cline and Fay 1990). Today’s ever-present cell phones have made it inexpensive and simple for parents to stay connected to their child, even when physically separated. It is theorized that the extension of the usual time period of parent-child close connection may prolong the child and young adult’s dependence upon parent and family resources. • There is no single “best” parenting style universal to all children. It is believed that a child’s internal state of fear, arousal, and anxiety is integral to their receptiveness to social learning; the best child outcomes appear to result when a parent’s style is in harmony with the child’s temperament. 28
  • 29. Child Influence on the Parent • The parent-child relationship is reciprocal, with each influencing the other’s thoughts, feelings, and behavior. Parents and children develop a long history of interaction; each acquires a set of expectations concerning the other’s behavior and establishes a method of interpreting the other’s reactions. • Disruptive behavior in a toddler holds less consequence, risk to the child, and threat to the parent than disruptive behavior in a teenager. Parenting affects children’s behavior most strongly during early childhood (Slagt et al. 2012) while problematic adolescent behavior strongly affects parenting (Reitz et al. 2006). Parental sense of competence is defined as a parent’s opinion of her ability to positively influence the behavior and development of her child (Coleman and Karraker 1998). • Social relations theory views children as active agents in their interactions with parents and assumes that disagreements, conflicts and changes occur frequently. It is developmentally normal for children to resist some of the socialization demands of their parents (Goh and Kuczynski 2009). A parent’s philosophy of parenting (style) and behaviors (parenting practices) will determine the degree of parent accommodation and submission to the natural resistance of the child. • It has been observed that a child’s status and power is higher in single-child homes. 29
  • 30. Application in Clinical Dental Practice- • The dentist and staff should continually monitor the ambient emotional tone in the office and quickly intervene in cases of negative emotional expression by parents. A parent who verbally or nonverbally expresses the stress of a bad day is not emotionally available to help his child and may unintentionally sabotage that child’s dental appointment. • If the dentist or staff member’s sincere and respectful attempt to redirect the parent to the intended positive purpose of the dental appointment is unsuccessful, the parent should be offered the opportunity to reschedule at a time when they are more in control. Sibling Influences- Throughout life, the sibling relationship may be cooperative, ambivalent, or antagonistic. The child grows and develops within a dynamic and variable family context across time. Multiple studies have confirmed that families differentially distribute such resources as parental time, attention, money, nurturance, and love among the children in a family. Parents tend to concentrate resources on some children and not on others. Parent resource inequity between siblings has been examined based on birth order, child gender, sibling gender, birth spacing, and birth intention (wanted versus unwanted pregnancy). Unintended children have been found to receive fewer parent resources than intended siblings (Barber and East 2009). Unwanted children are more likely to receive critical, punitive, abusive, and/or neglectful parenting (Barber et al. 1999). Inequitable treatment by parents has been found to have significant long-term negative effects on the adjustment and self-esteem of the slighted child. (McGuire et al. 1995; Volling and Elins, 1998). 30
  • 31. • Arrival of an infant has been found to adversely affect mother-to-older-sibling interactions with decreased maternal attention, positive affection, and attachment security, and often results in confrontations with the older child. It is theorized that increased behavior problems of the older child are mediated through changes in the mother-child relationship, particularly through increases in the mother’s use of physical discipline (Volling 2005). • It is important for the dentist to recognize the disruption and stress caused by new sibling(s) in the home and to realize that the transition of a child to the role of “big brother or big sister” comes at the cost of diminished parental attention. The child patient may show signs of stress in their new role and behave in a negative way to capture their parent’s attention. The goal should be to keep the focus and nurturing of the dental team directed toward the child patient, rather than on the newest family member and parent. The child patient can be invited to introduce his new sibling to the dentist or staff member. Examples of child-focused responses are: “It is nice to meet your new sister, but today, you are the special one!” and “This is a very lucky baby to have you for their own big brother!” 31
  • 32. Maternal influence on child’s dental behaviour- • While both the father and mother play important roles in their children's psychologic development , emphasis has usually been placed on the role of the mother. This is because mothers generally have more contact with their children than do fathers. • Maternal influences on children's mental, physical, and emotional development begin even before birth. It is well known that a mother's nutritional status as well as the state of physical health can affect the neurologic and somatic development of the foetus. • The expectant mother’s emotional state has also been correlated with certain postnatal behavioural patterns of the child. • It is believed that the foetus may be influenced by changes in the mother's neurohormonal system, which are transmitted through the placenta. Montagu has emphasized the importance of the prenatal environment on the later development of the child. He cites a study linking stimulation of the foetus to postnatal feeding difficulty, and another study in which mothers who underwent severe emotional stress during pregnancy tended to have excessively active, irritable infants. 32
  • 33. MATERNAL INFLUENCE ON PERSONALITY DEVELOPMENT- • While children's behaviour can influence the behaviour of mothers, research into parent-child relationships usually views the parent as the independent variable and the child as the dependent one. Bell has termed this relationship "one-tailed," since parental characteristics are viewed as having a unilateral influence on those developing in the child. • Bayley and Schaefer indicate that most of the relevant mother-child relationships fall into two broad çategories: autonomy vs control and hostility vs love . • Maternal attitudes and behaviors have been described and rated in relation to these two categories, and Schaefer has developed a model in which gradations of maternal behavior are arranged sequentially around the two reference pairings of autonomy vs control and hostility vs love. 33
  • 34. o The behaviour of mothers who participated in the Berkeley Growth Study was rated according to the attitudes depicted in the Schaefer model. The mothers' attitudes were then correlated with the behaviour of their sons. While there were some differences associated with the children's ages and other variable it was found that loving mothers tended to have calm, happy sons, while hostile mothers had sons who were excitable and unhappy. In general, mothers who allowed autonomy and who expressed affection had sons who were friendly, cooperative, and attentive. Conversely, punitive mothers and those who ignored their children did not have sons who exhibited these positive behavioural characteristics. The dental implications of the effects of maternal attitudes-in moulding children's personalities are apparent, as the friendly, cooperative child will probably also exhibit these traits in the dental office. 34 Love
  • 35. EFFECT OF THE MOTHER'S PRESENCE IN THE OPERATORY- • Many dentists prefer to exclude parents from the operatory. This attitude was confirmed in a study by Roder and co-workers, who sent questionnaires to 910 dentists to determine whether they preferred to treat children with the parent’s presence or absence. Nearly 70% of the dentists responded that they preferred to treat children with the parents absent; only 40 preferred the parents present. • It was concluded that the presence of the mother during the treatment of a well-behaved child does not increase the dentist's anxiety; thus, anxiety is probably not the reason the majority of dentists prefer to exclude parents from the operatory, it is quite probable that dentists generally prefer to have parents absent from the operating room while children are being treated because children behave satisfactorily without a parent present. 35
  • 37. 37
  • 38. Effect of the Parental Presence in the Operatory- • It is quite probable that dentists generally prefer to have parents absent from the operating room while children are being treated because most children behave satisfactorily without parental presence. In fact, as children get older and develop emotional independence, they themselves prefer they have their parent remain in the waiting room. • If a child exhibits uncooperative behaviour, the presence of the parent will sometimes lend support to this type of behaviour and it can also limit the range of behaviour control techniques of the dentist. Parent should not, however, be routinely excluded from the operatory as there are certain occasions when their presence is desirable and actually enhances positive behaviour on the part of child • Frankl found that children in age group of 42–49 months are benefited from mother’s presence. • Young children are more prone to a number of fears, like fear of unknown, and hence exhibit anxiety during short-term separation and the degree of response is affected by length of separations. 38
  • 39. Crying in the dental office- • It is not uncommon to witness a child who is crying while in the dental chair. All crying, however, should not communicate the same message to the dentist. Elsbach has described four types of children's cries: • Obstinate cry- child who ""throws a temper tantrum" to thwart dental treatment exhibits the obstinate cry. This cry is loud, high-pitched, and has been characterized as a siren-like wail. This form of belligerence represents the child's external response to his anxiety in the dental situation. • Frightened cry- The frightened cry is usually accompanied by a torrent of tears and convulsive, breath-catching sobs. The child emitting this type of cry has been overwhelmed by the situation. This child cannot be managed with the same techniques that would be used for the belligerent child. It is the dentist's responsibility to instill confidence in the frightened child by providing a series of carefully structured dental experiences that will allow the child to cope. 39
  • 40. • Hurt cry- The hurt cry may be loud; more frequently, however, it is accompanied by a small whimper. The first indication that the child is in discomfort may be a single tear welling from the corner of the eye and running down the child's cheek. The hurt cry is easily identified because the child will state, either voluntarily or when asked, that he is being hurt. Some children may be in pain but may control their physical activity so that the dentist is unaware of a problem. • Compensatory cry- compensatory cry as "not really a cry at all. It is a sound the child makes to drown out the noise of the dentist's drill.*"* Usually the sound is a droning monotone. While it may be annoying to the dentist, it is the child's way of coping with what he considers unpleasant auditory stimuli. The dentist should recognize the compensatory as a strategy the child has developed to cope with the anxiety that he is experiencing. It is a successful coping stratagem, and therefore the dentist should make no attempt to stop it. 40
  • 41. Parental Behaviour in the Dental Office - • Parental behaviour in the dental office also plays an important role in child management. Parents must understand that once the child is in the office, the dentist knows how to prepare the child emotionally for the necessary treatment. If a parent is invited into the treatment room, he must assume the role of a passive guest and either sit or stand away from the chair. Some instructions that should be told to the parents are: • Tell the parents not to voice their own personal fears in front of the child • Tell the parents never to use dentistry as a threat of punishment • Parents should familiarize their children with dentistry by taking the child to the dentist to become accustomed to the dental office and the dentist. • Explain to the parent that an occasional display of courage on his part in dental matters will build courage in the child 41
  • 42. • Consult the parent about the home environment and the importance of moderate parental attitudes in building well-adjusted child • Parents should stress the value of regular dental care, not only in preserving the teeth but also in formation of good dental patients • Discourage parents from bribing their child to go to the dentist • The parent should be instructed never to shame or ridicule to overcome the fear • The parent should not promise the child what the dentist is or is not going to do • Several days before the appointment, the parent should be instructed to convey to the child in a casual manner that they have been invited to visit the dentist. 42
  • 43. Parent–Child Separation • Wright noted that excluding the parent from the operating room could contribute in controlling the child’s positive behavior. Most dentists probably are more relaxed and comfortable when parent remains in the reception area and their action has positive effect on children’s behavior. • Some factors which influence the dentist not to include parent in the operatory are:  Parents often repeat orders, creating an annoyance for both dentist and child patient  Parents impose orders, becoming a barrier to the development of rapport between the dentist and child  Dentist is unable to use voice intonation in the presence of the parent because he may be offended  Child divides attention between parent and dentist  Dentist’s attention is divided between parent and child. 43
  • 44. Demographics-  Most studies find that negative behavior in the dental office is most intense in younger children and decreases as children grow older. Dental anxiety also decreases as the child grows older, as does needle phobia, most likely due to maturing communication and coping skills. However, it is important to assess the patient’s degree of psychological development because that may be more important than chronologic age when predicting disruptive behavior.  The role of gender in dental anxiety and misbehavior is not as clear. The majority of studies found increased anxiety in females, particularly after children pass early school age,while others found no difference. Klingberg and Broberg concluded in a 2007 review of the literature that a clear trend exists, with girls being both more dentally anxious and exhibiting more behavior management problems, which was in contrast with an early 1982 review where no clear difference in gender was found. This may be in part due to increased willingness for females to verbalize fears because of cultural norms for gender. 44
  • 45. ROLE OF DENTIST IN CHILD’S BEHAVIOUR- Appearance of dental office:  Make one corner of waiting room for the child only where he can play, sit, and read  Record player playing soothing music to ease fear  Appointment cards to be appealing to the child  Operating room should be appealing to the child having cartoon and pictures on walls  Time and length of appointment: Better to have morning appointments and also prevent appointments during the child’s sleeping, playing, or eating time. Duration should be short. 45
  • 46. • Dentist’s skill and speed: Dentist should be skilled or he will lose the child’s confidence • Attention to patient: Treat the patient as he is the only one seen during that day. Never leave him alone in chair and do not change rooms as all this increases anxiety • Dentist’s conversation: Keep talking to the child to gain his confidence. Use simple words and answer all questions. • Use of simple words: Do not use fear promoting words like needle, injection • Reasonableness of dentist: Be realistic and reasonable. Try to put yourself in the child’s place and see why he behaves in this particular way. • Use of admiration, subtle flattering, praise, and reward: Enforces the behavior for future • Self-control of dentist: Dentist should never lose his temper. It is a mark of defeat and indication to child that he has succeeded in undermining your dignity 46
  • 47. References • Behavior Management in Dentistry for Children , Edited by Gerald Z. Wright Ari Kupietzky • Ripa LW, Barenie JT. Management of Dental Behavior in Children. 1979. • Casamassimo PS, Fields HW, McTigue DJ, Nowak A. Pediatric Dentistry - ,Infancy through Adolescence,5. Elsevier Health Sciences; 2012. • Dean JA. McDonald and Avery’s Dentistry for the Child and Adolescent - E- Book. Elsevier Health Sciences; 2021. • Textbook of Pediatric Dentistry by Dr Shobha Tandon, Third Edition. • Marwah N. Textbook of Pediatric Dentistry. JP Medical Ltd; 2018. • Arathi Rao, Principles & practice in Pedodotics 47