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Dr. Aseel H. Al-Assadi

Management of Children Behaviors Behavior Management

It’s the means by which the dental health team effectively and efficiently

performs treatment to the child, without behavior management it is very hard to treat

children so our aim is to create a positive dental attitude to the children. They are basically about communication with the pt. and his parents and about educating the

child how to behave in dental clinic.

It's about communication and education to decrease the anxiety and fear and

to promote understanding to achieve good oral health. Individuals usually differ. So the appropriate management should be chosen depending on the individual’s needs,

every practitioner integrates his/her personality on the basic psychological principles

in managing children, So what works with one may not necessarily work with the other.

Definitions Behavior: It is an observable act, which can be described in similar ways by more than one

person.

Child dental management: It is a clinical art form and still built on a foundation of

science which can be defined as the means by which a course of treatment for a young patient

can be completed in the shortest possible period, while at the same time ensuring that he will

return for the next course willingly.

The goals of behavior management are: • To establish communication with the child and the parents.

• Alleviate fear and anxiety to provide a relaxing and comfortable environment for the dental

team to work in, while treating the child.

• Deliver quality dental care

• Build a trusting relationship between dentist, parent and child.

• Promote child’s positive attitude towards oral/dental health.

FUNDAMENTALS OF BEHAVIOR MANAGEMENT 1) The team attitude

2) Organization

3) Positive approach 4) Truthfulness

5) Tolerance

6) Flexibility

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Behavioral Pedodontics A professional goal is to promote positive dental attitudes and improve the dental health

of society. Logically, children are keys to the future. Since childhood experience plays an

important role in forming the adult behavior, proper behavior management from the early stages

will help in the development of a proper oral health attitude among individuals throughout life.

A major difference between the treatment of children and the treatment of adults is the

relationship. Treating adults generally involves a one- to -one relationship, that is, a dentist-patient

relationship. Treating a child, however, usually relies on a one-to-two relationship among the

dentist, the patient, and parents or caregivers. This relationship, known as the pediatric dentistry

treatment triangle.

Because these individuals and their relationships cannot be segregated from external

influences, the triangle is encircled by society. Management methods acceptable to society and the

litigiousness of society have been factors influencing treatment modalities. The child is at the apex

of the triangle and is the focus of attention of both the family and the dental team. Although

mothers’ attitudes have been shown to significantly affect their children’s behaviors in the dental

office, the roles of families have been changing, and the entire family environment must be

considered. Because changes are constantly occurring within each personality, one must remember

that there is an ever-changing, dynamic relationship among the corners of the triangle—the child,

the family, and the dental team. The arrows placed on the lines of communication remind us that

communication is reciprocal.

The relation here is not just you and the pt. it's a three way process, other say

it's 4 way process ( you, the pt. , his parents , and dental team ) it's a dynamic process

that starts before the pt. arrives and it involves dialogue, voice tone, facial expressions, body language, and touch. some people don't like to use the word

management because they think it's a little

harsh so they use "Behavioral Guidance" instead, because it guides the child toward

communication and education, using a

continuous interaction involving the dental

health team, the dentist, the patient and his parents leading to a good dental treatment

and creating a positive experience to the

child himself.

PEDIATRIC DENTAL PATIENTS Although there may be expectations for children’s skills based upon chronological age, the

practitioner must assess the individual child’s understanding and be familiar with the family

environment. Differences in genetics, personality, and experience influence the way the child

engages with his surroundings. If influences are in harmony, healthy development of the child can

be expected; if they are dissonant, behavioral problems are almost sure to ensue. Key to a

practitioner’s interaction with a child is remembering that each child is unique and exists in the

context of his family.

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Child development Child development involves the study of all areas of human development from

conception through young adulthood. It involves more than physical growth, which often implies

only an increase in size. Development implies a sequential unfolding that may involve changes in

size, shape, function, structure, or skill.

Major area of development 1. Physical development

Physical development is a term used to describe the child’s total physical growth and

efficiency from the moment of conception until adulthood together. The broad area of physical

development involves changes that occur in children’s size, strength, motor coordination,

functioning of body systems, and so forth.

Because a child’s physical development is relatively independent of other major areas of

development, subareas of physical development must be relatively independent. Child’s

coordination cannot be judged by physical size and the physical strength is not related to dental

development.

Relating key aspects of development to chronologic ages has led to the establishment of

developmental milestones as a means of assessing individual children. Each child is unique and

may develop at varying rates relative to their same-aged peers, For example, one child may

present with strong motor skills but less well-developed language, while this may be the opposite

for another same-age peer. Typical personality characteristics related to specific chronologic

ages that have relevance to dentistry are listed below which can help in the development of

behavioral guidance strategies:

Age-Related Psychosocial Traits and Skills for 2- to 5-Year-Old Children

TWO YEARS

Geared to gross motor skills, such as running and jumping

Likes to see and touch

Very attached to parent

Plays alone; rarely shares

Has limited vocabulary; shows early sentence formation

Becoming interested in self-help skills

THREE YEARS

Less egocentric; likes to please

Has very active imagination; likes stories

Remains closely attached to parent

FOUR YEARS

Tries to impose powers

Participates in small social groups

Reaches out—expansive period

Shows many independent self-help skills

Knows “thank you” and “please”

FIVE YEARS

Undergoes a period of consolidation; deliberate

Takes pride in possessions

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Relinquishes comfort objects, such as a blanket or thumb

Plays cooperatively with peers

From these data, two pieces of information about development milestone: 1. the

average age at which a child acquires particular skills. 2. The normal range of ages at which the

skill is acquired.

Knowing the general developmental principle reminds the clinician to consider the

ability or readiness of the individual to perform a given task.

2. Social development

It include both interpersonal relationships and independent functioning skills. An

important process for dentists is the child’s growth toward independent functioning. For their

survival, infants are dependent on others to clothe, feed, and nurture them. As children grow and

their ability to care for themselves improves, they gain social independence.

Recognizing that the change from functional dependency to functional autonomy is a

normal process in social development can assist the dentist. Many young children want to brush

their own teeth but lack sufficient digital dexterity. Parents, on the other hand, understand the lack

of digital skills and often insist on attending to their children’s oral health care.

3. Intellectual development (mental development)

Intellectual development is probably the area most comprehensively studied, it is

the method that employed quantified mental abilities in relation to chronologic age. It led to the

concept of the intelligence quotient (IQ), which was measured by tasks examining memory, spatial

relationships, reasoning, and a variety of other primary mental skills. This enabled an examiner to

determine a child’s mental age based on performance. The basic Binet IQ formula used is:

IQ= (mental age/ chronological age) × 100

So, the child whose mental age and chronological age were identical had an IQ of

100. The 8-year- old child whose mental age was 6 would have an IQ of 75(6/8×100=75), and

the 4-year- old child with 6- year mental age would have an IQ of 150 (6/4×100=150).

Individuals with intelligence deficiency or intellectual disability may require

special behavior guidance.

The Wechsler Intelligence Scale for Children (WISC), developed by David

Wechsler, is an individually administered intelligence test for children aged 6 years- 16 years and

11 months. The WISC-V takes 45–65 minutes to administer and generates a Full Scale IQ

(formerly known as an intelligence quotient or IQ score) which represents a child's general

intellectual ability. The WISC is used not only as an intelligence test, but as a clinical tool. Some

practitioners use the WISC as part of an assessment to diagnose attention-deficit hyperactivity

disorder (ADHD) and learning disabilities, for example. This test provides a broad assessment of

general intellectual functioning and school-related abilities. Wechsler intelligence scales are

available for preschoolers (Wechsler Preschool and Primary Scale of Intelligence, or WPPSI),

children (Wechsler Intelligence Scale for Children-Revised, or WISC-R), and adults (Wechsler

Adult Intelligence Scale, or WAIS).

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Anxiety and Fear Fear (Apprehension based on history): It is a primal emotion which stems from a

recognized source developed to protect the individual from harm and self-destruction it has safety

value when given proper direction and control. The subject is able to pinpoint what he/she is afraid

of e.g. fear of needle. Fear sets in a series of physiological responses to prepare a subject for

fight/flight response.

Anxiety (Fear of the unknown): It is one of the primary emotions acquired soon after

birth. It is a personality trait and is apprehension, tension or uneasiness that stems from anticipation

of danger, the source of which is largely unknown or unrecognized.

There is no clear division between fear, anxiety and other responses to stress. Fear and

anxiety can intensify pain or misattribute pain e.g. Events which are not pain provoking can be

perceived as painful.

Phobia (Pathological fear): It is persistent, excessive, unreasonable fear of a specific

object, activity or situation, attached to a certain stimulus. It is deep seated and is provoked by any

stimulus which resembles the original episode.

Fear is best understood within a multifactorial context of personal, environmental, and

situational factors in combination with the child’s development and intelligence. Fearfulness is a

personality trait often associated with temperament, shyness and negative mood. Most of the time

parents instill the fear of dentistry in their children as a means of punishment. Fear should be

channeled in the correct direction such as those that causes harm to the child’s existence or

wellbeing. Children should be taught that dental office is not a place to fear, and the parents should

never employ dentistry as threat or punishment. Using it in this manner creates fear of dentistry or

dentist. On the other hand if the child has become attached to the dentist, fear of loss of his approval

may have some value in motivating the child for dental treatment.

The child’s fears change with age;

Two Years Old

They are in precooperative stage of lacking cooperative ability. Solitary play is preferred, as

child has not yet learned to play with other children. Fear or anxiety of this age group is fear of

falling, sudden jerky movements, bright lights, separation from the parents and fear of strangers.

Three Years Old

Communication is easier. Child has great desire to talk and often enjoy telling stories. Fear of

this age group is fear of strangers.

It is the right time to introduce the child to dentistry. This is also the appropriate time to begin any

preventive procedures.

Four Years Old

They are usually listeners to explanations with interest and normally responsive too verbal

directions. They usually have lively minds and may be great talkers, although they tend to

exaggerate in their conversation.

In some situations they may be defiant. There is increased ability to evaluate fear producing

stimulations. Intelligent children display more fear, may be because of greater awareness of the

danger and reluctance to accept verbal assurance without proof.

Fears of this age group: Fear of falling, of noise and of strangers is lessoned. Fear of bodily injury

is present. Prick of hypodermic needle or sight of blood produces increased response

disproportionate to that of pain.

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Fears of 4-8 years old Children are related to prior situations and experiences. They begin to anticipate situations

and react with fear. During this period fantasy plays a role, and gains comfort and the courage to

meet the real situation. Intelligent children display more fear because of their greater awareness of

danger and reluctance to accept verbal assurance.

Fears of 9 years of age Fear is usually associated with personal failures and social peer situations. Child can usually

resolve fears of dental procedures if dentist explains and reasons will. Child has also learned to

tolerate unpleasant situations and has marked desires to be obedient, carrying frustrations well.

The child develops considerable emotional control. However, objects to people making light of

his suffering, bullying, injustice or ridiculing whether it is from a friend or a dentist.

Fears are of two types: A child may experience two types of fear during dental treatment:

1. Objective fears

2. Subjective fears

Objective fears: These are acquired objectively or those produced by direct physical stimulation

of the sense organs (seen, felt, smelt, or contacted) but not of parental origin, which are

disagreeable and unpleasant in nature.

• Fears from previous unpleasant contact with dentistry

• Unrelated experiences like repeated hospitalization leading to fear of uniforms worn by dental

team or even characteristic smell of hospital, drugs or chemicals associated with unpleasantness

arouse fear.

Subjective fears: These are based on the feelings and attitudes suggested to the child by others

without the child personally experiencing them. These are imitative, suggestive or imaginative

fears. Suggestive fears are acquired by imitation by observation of others. These imitative fears

are transmitted while displayed by others (parent) and acquired by the child without being aware

of it. They are generally recurrent, deep seated and are difficult to eradicate. Displayed emotion in

parent’s face creates more impression than verbal suggestions. Even a tight clenching of the child’s

hand in dental office while undergoing dental treatment crates fear in child’s mind about dental

treatment. These fears also develop from friends, playmates, reading books and periodicals,

watching media and theater and depend on repetition.

**Value of fear: Fear lowers the threshold of pain so that every pain produced during dental

treatment becomes magnified.

Since our aim is to reduce anxiety, what's dental anxiety? It’s a vague, unpleasant

feeling accompanied by appropriation that something undesirable is about to happen. You need to

know about preexisting anxiety term. Dental anxious children are more sensitive to dental pain.

The word anxiety differs from the word fear, in Fear you know what you are afraid of (more

specific) in anxiety it's (more generalized) still we can use them interchangeably but it's good to

know the difference. An old American study had showed that visiting dentists is rank 4 that causes

anxiety to people behind, snakes, heights, and storms, so people don't really like visiting us. The

most procedure that causes anxiety is local anesthesia, and then the sound of the drill (hand pieces).

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Q: How can we tell that someone is anxious? 1. Physiological manifestation (physiologic and somatic sensation) Perspiration palpation,

breathlessness, and anything that affects body function.

2. Cognitive features he loses his ability to focus, that's exactly what happens to us during exams.

3. Behavioral features it's like because you're anxious you start not going to the dentist, you start

avoiding or postponing the dental appointment.

Q: How do you measure anxiety?

By measuring the 3 manifestation that we talked about.

1. Physiological measures: heart rate, hand and face temperature.

2. Cognitive features measures: they may ask the pt. specific questions and know the level of the

pt. anxiety, they ask simple questions and they have to make sure that the questions are reliable

and valid, they are not haphazard questions. Ex: ''how about visiting the dentist?'' they take one of

the boxes and add up to the score and then we can decide their level of anxiety based on this scale.

Children who are very young (who can't read yet) we show them faces scale or a pie test. Ex: “how

do you feel about going to the dentist?'' we ask him to choose the face that tells what he feels. It's

so useful to know the level of anxiety to help us in the management, (interviews, questionnaire,

and self-report measurements) Venham picture test for small children. corah's dental anxiety scale

for older children and adults.

3. Observing: we observe the child behavior and put him on a scale

CLASSIFYING CHILDREN’S COOPERATIVE

BEHAVIOR Numerous systems have been developed for classifying children’s behavior in the dental

environment. An understanding of these systems can be an asset to the dentist in several ways:

assisting in directing the behavior guidance approach, providing a means for the systematic

recording of behaviors, and assisting in evaluating the validity of current research.

Behavior patterns of a child can be classified in various ways:

I) According to age • Pre-cooperative stage-less than 2 years

• Cooperative stage-above 2 years The pattern of child behavior at certain age with expected development:

* 2-year-old children: Dentists sometimes refer to such children as being in the pre-

cooperative stage and often referred to as being in the stage of the “terrible twos.”

* 3- year-old children: Children communicate more easily than 2 years old, but they need

their parents to remain with them in clinic to feel more security.

* 4- year-old children: The child usually listens and has a response with interest to dentist

explanation and verbal direction.

* 5- year-old children: If the child properly prepared by the parents, he will have no fear of

new experience.

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*6- year-old children: The child need proper introduction about dental treatment in order to

respond in a satisfactory manner because the tensional manifestation rise to peak at this age.

II) According to Clinical classification of behavior patterns Wright’s clinical classification places children in one of three categories:

• Cooperative

• Lacking cooperative ability

• Potentially cooperative

Note: When a child is being examined, his/her cooperative behavior is taken into account

because it is a key to the rendering of treatment. Most children seen in the dental office

cooperate.

Cooperative children are: 1) Reasonably relaxed.

2) They have minimal apprehension and may even be enthusiastic.

3) They can be treated by a straightforward, behavior-shaping approach. When guidelines for

behavior are established, these children perform within the framework provided.

Lacking in cooperative ability children are (In contrast to the cooperative

children): This category includes 1) Very young children with whom communication cannot be established and of whom

comprehension cannot be expected. Because of their age, they lack cooperative abilities.

2) Another group of children who lack cooperative ability is those with specific debilitating

or disabling conditions. The severity of the child’s condition prohibits cooperation in the

usual manner.

At times, special behavior guidance techniques are used for these children. Although their

treatment can be carried out, immediate major positive behavioral changes cannot be expected.

Potentially cooperative child is “behavior problem”: This type of behavior differs from that of children lacking cooperative ability

because these children have the capability to perform cooperatively. They have the ability to

cooperate but they choose not to (the most challenging pts.) and they are the most common pts

you are going to meet. This is an important distinction. When a child is characterized as

potentially cooperative, clinical judgment is that the child’s behavior can be modified; that is, the

child can become cooperative.

The adverse reactions have been given specific labels for descriptions of potentially

cooperative patients, so that potentially cooperative group are further categorized as follows:

1. Uncontrolled behavior

Seen in 3-6 years.

Tantrum may begin in the reception area or even before.

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This behavior is also called as ‘incorrigible’.

Tears, loud crying, physical lashing out and flailing of the hands and

legs- all suggestive of a state of acute anxiety or fear.

School aged children tend to model their behavior after that of adults.

If it occurs in older children, there may probably be deep rooted

reasons for it.

2. Defiant behavior (challenging one) (Also referred to as “stubborn” or

“spoilt”)

When the child starts getting older, he will try to resist you,

small children refuse to open their mouth by saying '' I don't want to''

but when they are a little bit older they will sit and open their mouth

but at the same time they will start pushing you by their hands.

Can be found in all ages, more typical in the elementary school group.

Distinguished by “I don’t want to” or “I don’t have to” or “I won’t”.

They protest when they are brought to the dental clinic against their will, as they do at

home.

Once won over, these children frequently become highly cooperative.

3. Timid behavior

They are (Mostly female) they hide their faces by their hands or

hide behind their mother and maybe at any time they deteriorate to

uncontrolled. Milder but highly anxious.

If they are managed incorrectly, their behavior can deteriorate to

uncontrolled. May shield behind the parent.

Fail to offer great physical resistance to the separation.

May whimper, but do not cry hysterically.

May be from an overprotective home environment or may live in an isolated

area having little contact with strangers.

Needs to gain self-confidence of the child.

4. Tense cooperative behavior

> 7 years, they try to help us but they are very anxious, we call them white

knuckles, they hold something with their hand(s) in a constant position, a chair for example so their knuckles become white.

Border line behavior

Accept treatment, but are extremely tense

Tremor may be heard, when they speak

Perspire noticeably

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5. Whining behavior

(No pain, no tears) just ''naaaaaa'' Usually continuous, it's annoying. They do not prevent treatment, but whine throughout the procedure

Cry is controlled, constant and not loud

Seldom are there tears

These reactions are at times frustrating and irritating to the dented team

Great patience is required while treating such children

III) According to Frankl’s Behavior Rating Scale

• Rating 1: Definitely negative. Refusal of treatment, forceful crying, fearfulness, or any

other overt evidence of extreme negativism (Defiant behavior)

• Rating 2: Negative. Reluctance to accept treatment, uncooperativeness, some evidence of

negative attitude but not pronounced (sullen, withdrawn) (Timid and whining behavior)

• 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 (Tense co-operative, Whining and timid)

• Rating 4: Definitely positive. Good rapport with the dentist, interest in the dental

procedures, laughter and enjoyment.

Wright (1975) added symbolic modifications to the Frankl’s rating scale and

made it more applicable and easier to understand child behavior:

Rating no. 1 - definitely negative (- -) Rating no. 2 - negative (-)

Rating no. 3 - positive (+)

Rating no. 4 - definitely positive (++)

Parent-child relationship It is “one-tailed” relationship where parent is an independent variable and child is the dependent

one.

(I) Effects of parental attitudes (types of parents)

Parental attitudes can be of the following nature:

1. Overprotection i.e. exaggeration of love and affection. Overprotective parents take excessive

care of their children .They do not allow the children to take any risks. They ‘infantize’ their

children. Factors responsible for overprotection can be:

a) History of previous miscarriage or a period of sterility before the child’s birth.

b) Death of a sibling or if the mother cannot bear more children.

c) Family's financial status.

d) Absence of either parent

e) Illness or physical handicap in the child.

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2. Overindulgence

Parents give children whatever they want without any restraint. The child becomes spoilt and

is accustomed to getting his own way. The child’s emotional development is impaired. In the dental

clinic, the children may show temper tantrums when they cannot control situations.

3. Underaffection: It may manifest as:

i) Mild detachment

ii) Indifference

iii) Neglect

This can be due to the parents having little time and concern for the children; or if child is

unwanted due to some reason. The children are usually well-behaved; shy and indecisive. They

cry easily, but respond well when treated with a little affection.

4. Rejection: These children lack the feeling of belonging. They are anxious, aggressive,

overactive, disobedient and ’attention seekers’. The causes of rejection are:

i) Unwantedchild

ii) Unhappymarriage

iii) Birth of the child not anticipated

iv) If child’s presence interferes with parental careers or ambitions.

v) If the mother herself is immature or emotionally unstable.

5. Authoritarianism

Parents induce discipline in the form of physical punishment or verbal ridicule. They insist that

the child should follow their set of norms and extend many efforts to train the child as per their

expectations. The parents are non-love oriented. The children are submissive with heightened

avoidance gradient. They delay response and exhibit evasive behavior.

6. Identification

Parents try to re-live their lives through their children. In doing so, they give children everything

that had been denied to them. If the children do not respond favorably, parents display overt

disappointment. The children carry a sense of guilt which is mirrored in shyness, retirement and

unsurety. They are generally good dental patients but need to be handled with kindness and

consideration.

(II) Effects of parent’s presence in the operatory

It is better to let them wait in the waiting room and not to be in the clinic during the

procedure, but this is not easy, anyway most researches suggested that children’s behavior is not

affected by the presence or the absence of their parents, unless they are very young less than 4

years (better to present). A new study showed that parents really like to be with their children in

the clinic and primary reason for that is ''comfort'' to feel comfort about their child.

So many parents prefer to be there during the procedure, especially if the patient is too

young or it's his first visit, but our main concern as dentists is that their presence may lead to

inappropriate communication with the child, or they may exhibit anxiety themselves.

Parents always repeat orders and this creates annoyance for both child and dentist, and

may break the rapport between the child and the dentist, and makes it harder to use the (voice

control). -we will talk about it later on. What is essential? To explain the whole procedure and to

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talk about what is the best for the patient and for his parents. Dentists generally prefer to have

parents outside the operating room because most children behave satisfactorily in the absence of

parents. If the child is uncooperative, parent's presence may support his behavior and limit the

range of behavior control techniques of the dentist.

However, in some cases, parent’s presence may be desirable i.e.

i) Children of 1-3 years of age

ii) Children during their first dental visit.

iii) Handicapped children.

For obtaining desirable behavior from children; following instructions should be given to

parents:

1. Do not express your fears in front of children.

2. Never use dentistry as a threat or punishment.

3. Familiarize the child with dentistry by taking him to a dentist to become accustomed to dental

office.

4. Expressing occasional display of courage builds courage in the child’s mind.

5. Advise and instruct your children about regular care.

6. Never scold the children to overcome the fear of dental treatment.

7. Never bribe your children to go to a dentist.

8. Never promise the children what the dentist is not going to do.

9. Carry the child to the dentist in a casual manner without being over-sympathetic.

10. Do not enter the operatory unless desired.

VARIABLES INFLUENCING CHILDREN’S DENTAL

BEHAVIORS Dentistry has had some difficulty identifying the stimuli that lead to misbehavior in the

dental office, although several variables in children’s backgrounds have been related to it. Those

variables are of two types:

1. Major variables

2. Minor variables

1. Major variables

(1) Parental anxiety

because children when they are very young, they learn everything from their parents, and

that's what we called (primary socialization) it lasts for life long, but its effect is reduced when the

children go to the school and we call it here (secondary socialization), it is an ongoing and gradual

process, so parents can shape their children's attitude toward oral health.

The importance of the maternal anxiety has been reported and recognized for over 100

years, especially for those less than 4 years old. Parents are also capable of predicting their child's

behavior, they can pretend if he's going to cooperate or not, and it's well documented, if the child's

mother is anxious, or she can't even look while we're doing the treatment we can ask another

member to come with the child to the clinic, so if the parents are afraid of dentists the child of

course will be afraid too. In the past, it has been customary for mothers, more often than fathers,

to accompany children to the dental office. Children respond with tension and fear primarily

because of the way dental experiences have been described to them. The problem of dental fear is

not specific to dental situations or procedure. The behavior of a child is found to be directly

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proportional to the level of parental anxiety in which a significant correlation between maternal

anxiety and a child’s cooperative behavior at the first dental visit. Children of mothers with high

anxiety levels exhibit more negative and uncooperative behavior. High anxiety on the part of

parents tends to affect their children’s behavior negatively. Children of all ages can be affected by

their mothers’ anxieties but the effect is greatest with those younger than four years of age. This

might be anticipated because of the child-parent symbiosis that begins in infancy and gradually

diminishes.

(2) Past medical history

A child who have had a negative experience associated with medical treatments (a lot of

surgeries and a lot of appointments) will be anxious of dental treatment even though they didn't

try it, or maybe a negative experience from previous bad dental visit. Children with pleasant past

medical experiences are more likely to be cooperative; but past experience of pain or negative

attitude of the child towards physician results in a negative behavior in the dental operatory. The

emotional quality of past visits rather than the number of visits is significant. The behavior of

children with special health care needs may differ from that of healthy children. Those with chronic

medical conditions (without developmental delay) can become “adultified.” Because of recurring

medical experiences, they may become accustomed to the health care setting and behave “better”

than expected.

Pain during previous health care visits is another consideration in a child’s medical

experiences. The pain may have been moderate or intense, real or imaginary. Parental beliefs about

past medical pain are significantly correlated with their children’s cooperative behavior in the

dental environment. Previous surgical experiences adversely influence behavior at the first dental

visits, but this was not the case in subsequent visits.

(3) Awareness of dental problems

When a child came to the dental clinic with cellulites, with pain, and he didn't sleep the

whole night, his first dental visit will be anxious because he knew that something will going to

happen, ideally we prefer to see the child for the first time for checkup, hence, children who know

they have a dental problem, exhibit more negative behavior at the first dental appointment. Some

children visit the dentist when they are made aware of an existing problem .The problem may be

as serious as a chronic dental abscess or as simple as extrinsic staining of the dentition. However,

there is a tendency toward negative behavior at the first dental visit when the child believes that a

dental problem exists which is likely to make them more apprehensive as the question “what will

be done" comes in their minds. Concern about the presence of caries may also lead to missed

appointments. The significance of this variable provides the dentist a good reason for educating

the parents regarding the value of having the child's first visit prior to any dental problem.

2. Minor variables

(1) Socio-economic status of the family directly affects child's attitude toward the values of the

dental health process. Those of low socio-economic class, below average education, have a

tendency to attend dental needs when symptom dictates. These families harbor anxiety from dental

treatment and these children take on these fear and tend to be less co-operative.

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(2) Position of the child in the family (rank of the child)

The older child may become more anxious than children born later while middle child is

usually more outgoing and suggestible because he use his older sibling and parent as behavior

pattern to follow.

(3) Child gender

The responses of children to the dental environment are diverse and complex. The clear effect

of the child gender on behavior can be seen in the dental environment for example boys are

expected to be brave stronger than girls (boy act as man and does not cry). Girls exhibited more

dental anxiety and dental behavior management problems than did boys.

(4) Child age There different types of fear at different ages, like in 2-4 years fear of imaginary creatures

and small animals then 4-6 years start social and school fear. Fear related to injury, death and so

on is shown in those 6 years to adolescent.

(5) Contemporary influences include social experiences, attending nursery school and peer

interactions

The experiences of a child during formal learning at school, summer camps or peer-interactions

may be of help to the dentist in determining their level of cooperation. Those attend nursery school

cooperate more with the dental procedure. Communication technologies and media also have a

strong influence on the child's behavior.

(6) Modeling or imitation

It can be considered as the most effective means to introduce the child to dentistry, also

it is effective for patients who have no previous dental visit.

Some general consideration of pediatric patients’ management: 1. Always call the patient by his (first/ nick) name.

2. Direct the conversation toward the child whenever possible.

3. Talk at the child’s level (physically and mentally).

4. Avoid quick and sudden movements while performing the procedure.

5. Avoid fear promoting words.

6. Communicate with the patient, but once the treatment starts you need to use short commands.

7. Admire and praise the good behavior, because children like to please adults.

8. Keep self-control all the time, it's not acceptable to lose it, especially while dealing with the

pediatric or handicapped patients.

Some factors that might contribute to the child’s behavior

(related to the dentist):

1. Scheduling: when to see the patient is very important, most children are fresher in the

morning, we prefer see them in the morning specially pre schooled ones, and we prefer same age

group to be there at the same period so they will be comfortable when they see children who are

from their age group, another thing is how much will they wait? Because waiting too much in the

reception area leads to tiredness and restlessness.

2. Appointment length: new researches suggest to treat each Quadrant in each appointment

(ex: to treat The 6+E+D at one appointment) creating less numbers of appointments, usually the

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patient loses his concentration if the appointment is more than 30-45 minutes), on the other hand

one clinical study stated that the length of the appointment doesn’t affect the behavior negatively

and another one stated that it affects the behavior positively.

3. Dental Attire: Some Pediatrics have a negative experience toward the white coat and the

mask, especially those who were under GA, and this makes their management harder, so some

pediatric dentists tend to wear colorful clothes, but some of them refuse that because they say it is

less professional, thus "the dental attire" is a personal choice.

**As a summary:

FACTORS INFLUENCING CHILD’S BEHAVIOR:

1. Factors involving the child

• Growth and development

• I.Q of the child

• Past dental experience

• Social and adaptive skill

• Position of the child in the family

2. Factors involving the parents

•Family influence

•Parent-child relationship

• Maternal anxiety

• Attitude of parents to dentistry

3. Factors involving the dentist

• Appearance of the dental office

• Personality of the dentist

• Time and length of appointment

• Dentist’s skill and speed

• Use of fear promoting words

•Use of subtle, flattery, praise and reward.