Modification of Child's Behavior

8/13/2019 Modification of Child's Behavior

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Contents: Introduction Classification of behavior

Patient management by 5 domains:1. Physical domain2. Pharmacological domain3. Aversive domain4. Reward-oriented domain5. Linguistic domain

Dentist as an oncological coach.Basic behavior management techniques

Preappointment experienceUse of euphemismsDesensitizationTell-show-do techniqueModellingContingency management


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Implosion therapyHand over mouth

Voice controlPhysical restraint

Praise and communication Voice clarityMultisensory communication

Non verbal advantageThe placeCategories of non verbal advantageMastering the non verbal advantageBehavior shapingRetraining

Practical considerationsDental homeConclusionReferences


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Introduction Each day, in thousands of dental offices, a pediatric dental patiententers the treatment room.

Immediately there is an increase in the heart rate, elevated bloodpressure, quivering knees and lips, tears rolling down cheeks.

Unfortunately, this scenario can apply to both the patient and thetreating dentist and dental auxiliary.

First visit to the dentist should provide for a foundation of pleasantexperiences and attitudes for future oral healthcare.

By learning some basic behaviour modification techniques, pediatricdentists and auxiliaries can provide a non-threatening and comfortableenvironment for the very youngest of patients.


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Behavior:

It is an observable act, which can be described in similar waysby more than one person. It is defined as any changeobserved in the functioning of an organism. Learning asrelated to behavior is a process in which past experience orpractice results in relatively permanent changes in anindividuals behavior.

Behavioral Pedodontics: It is a study of science which helps to understanddevelopment of fear, anxiety and anger as it applies to child indental situations.

Dr. David Chambers, a psychologist labelled the availableways dentists can handle children as an embarrassment ofriches.


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Wilsons classification (1933)

Normal or bold Child is brave enough to face newsituations, is co-operative and

friendly with the dentist. Tasteful or timid The child is shy, but does not interfere with the dental procedures.

Hysterical or rebellious Child is influenced by homeenvironment- throws temper tantrumsand is rebellious.

Nervous or fearful The child is tense and anxious, fearsdentistry


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Frankels classification(1962)

(Frankels behavior rating scale) Rating Behavior

Definitely negative(--) Refuses treatment, cries forcefully,extreamely negative behavior associated with fear.

Negative(-) Reluctant to accept treatment anddisplays evidence of slight negativism.

Positive(+) Accepts treatment, but if the child has abad experience during treatment, maybecome uncooperative.

Definitely positive(++) Unique behavior, looks forward to andunderstands the importance of goodpreventive care.


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Classification by Lampshire(1970)Co-operative Child is physically and mentally relaxed. Is

co-operative throughout the entireprocedure.

Tense co-operative Child is tensed and co-operative at the sametime.

Outwardly apprehensive Avoids treatment initially, usually hidesbehind the mother, avoids looking or talkingto the dentist. Eventually accepts dentaltreatment.

Fearful Requires considerable support so as toovercome the fears of dental treatment.

Stubborn/Defiant Passively resists treatment by usingtechniques that have been successful inother situations.

Hypermotive The child is acutely agitated and resorts toscreaming, kicking etc.

Handicapped Physically/mentally, emotionallyhandicapped.

Emotionally immature


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Classification by Wright (1975)Cooperative(positive behavior) Un-cooperative(negative behavior)

Cooperative behavior-Child is cooperative, relaxed with minimalapprehension

Uncontrolled/hysterical/incorrigible- usually seenin-1. Preschool children at their first dntal visit2. Temper tantrums i.e., physical lashing out of

legs and arms, loud crying and refuses tocooperate with the dentist.

Lacking cooperative ability- usually seen in young child,(0-3yrs.),disabled child,physically and mental handicap

Defiant/obstinate behavior- can be seen in any agegroup. Usually in spoilt or stubborn children.Can be made cooperative.

Potentially cooperative- has the potential tocooperate, but because of the inherentfears(subjective/objective) the child does notcooperate.

Tense co-operative- boderline between positive andnegative behavior. Does not resist treatment butthe child is tensed at mind.

Timid/shy- seen in overprotective child.Is shy but cooperative.

Whining type- complaining type of behavior allowsfor treatment but complains throughout theprocedure.

Stoic- seen in physically abused children. They are

cooperative and passively accept all treatment without any facial expression.


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Patient Management by Domain

5 basic domains:

1. Physical domain2. Pharmacological domain3. Aversive domain4. Reward oriented domain5. Linguistic domain


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Physical DomainFor unmanageable children

1. Hand restraints by dental assistants.2. Use of tools: papoose board, pedi wrap.3. Use of tape, cloth wraps and belts.4. Mouth props.

Alternative: Drugs, G.A.

Disadvantages:ExpensiveSometimes dangerous

Objectives: The objectives of patient stabilization are to:1. reduce or eliminate untoward movement.2. protect patient, staff, dentist, or parent from injury.3. facilitate delivery of quality dental treatment.


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Indications:1. Emergencies on hysterical children.

2. Children who cannot be reached in language because of their age.3. Developmentally disabled children.4. Children who for whatever reason cannot cooperate with dentist.5. Patients require immediate diagnosis and/or limited treatment and cannot

cooperate due to lack of maturity or mental or physical disability.6. The safety of the patient, staff, dentist, or parent would be at risk without the

use of protective stabilization.7. Sedated patients require limited stabilization to help reduce untowardmovement.

Pre-requisite:Informed consent by parents/ guardians.


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Contraindications :

Cooperative nonsedated patients;

Patients who cannot be immobilized safely due to associated medical orphysical conditions.Patients who have experienced previous physical or psychological trauma fromprotective stabilization (unless no other alternatives are available).Nonsedated patients with nonemergent treatment requiring lengthyappointments.

Precautions :Careful review of the patients medical history to ascertain if there are anymedical conditions (eg, asthma) which may compromise respiratory function.Tightness and duration of the stabilization must be monitored and reassessedat regular intervals.Stabilization around extremities or the chest must not actively restrict

circulation or respiration.Stabilization should be terminated as soon as possible in a patient who isexperiencing severe stress or hysterics to prevent possible physical orpsychological trauma.


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Pharmacological Domain

Nitrous oxide- oxygen sedation, G.A., drugs like-oral-hydroxizine, promethazine, chloral hydrate, meperidine, diazepam, triazolam,chlorpromazine.I.M.-ketamine, midazolam(also I.V.)

Disadvantages: Any drug causing decreased respiration, depression of gag reflex, or makes child sleep isdangerous.Smaller the child- more dramatic the danger.

Pre-requisite:Parental understanding of the techniques, risks and alternatives.


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SedationObjectives: The goals of sedation are to:1. Guard the patients safety and welfare. 2. Minimize physical discomfort and pain.3. Control anxiety, minimize psychological trauma, and maximize the potential

for amnesia.4. Control behavior and/or movement so as to allow the safe completion of the

procedure.5. Return the patient to a state in which safe discharge from medical supervision,

as determined by recognized criteria, is possible.

Indications : Sedation is indicated for:1. Fearful, anxious patients for whom basic behavior guidance techniques have not

been successful.2. Patients who cannot cooperate due to a lack of psychological or emotional

maturity and/or mental, physical, or medical disability.3. Patients for whom the use of sedation may protect the developing psycheand/or reduce medical risk.

Contraindications: The use of sedation is contraindicated for:1. The cooperative patient with minimal dental needs.

2. Predisposing medical conditions which would make sedation inadvisable.


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Aversive Domain A technique can be described as aversive if its use on achild is objectionable enough that the child will cooperatein order to avoid the technique.E.g. Parental spanking.

Some techniques can be regarded as aversive if used aspunishment.

But such techniques should be avoided because:They are unwarranted.Legally dangerous.Probably will be ineffective.


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HOME (Hand Over Mouth Exercise)

by- Evangeline Jordon, 1920Can be practiced as a linguistic technique.If practiced aversively to quite a crying child or

screaming child informed consent needed.Its purpose is to gain the attention of a highlyoppositional child so that communication can beestablished and cooperation obtained for a safe course

of treatment.Last resort usually with children 3-6 yrs. of age, whohave appropriate communicative abilities.Parental consent is required.


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Reward Oriented DomainTo secure a child's cooperation.Use of reward by parents- negative effect onappointment.Child will think that parent is offering reward becauseappointment will be difficult, frightening or scary forthe child.

So no award before appointment should be offered.It should come as a surprise afterwards.


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Linguistic DomainThis involves conversation of the dentist with the childand the child with the dentist.Maturity in language is important for child which fornormal child occurs between 2-4 yrs. Of age.Dentist is a communicator, a teacher, a coach, arewarder, a psychologist, a distracter and an authority

figure.


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Requests and Promises

Cooperation in the human community happens when two or moreindividuals take effective actions together.Dentist must make effective requests and child must make effective

promises.Only when child declines a request, behavior management strategymust be initiated. This strategy will reframe the original request.The essence of reframing is that it convinces the child that the dentistis serious about the request.


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ReframingIt is defined as taking the situation outside the framethat upto that moment contained the individual indifferent conditions, and visualize (reframe) it in a wayacceptable to the person involved and with thisreframing, both the original threat and the threatenedsituation can be safely abandoned.(Benjamin Peretz1999)


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The Dentist as an Ontological Coach

Ontology means Our way of being.Best way for a child during appointment is quite,listening for requests, and cooperating with therequests.So, dentist should not only be educator or requestor,but also be an ontologic coach in trying to make the

childs way of being during the dental appointmentappropriate for linguistic techniques.


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Basics in managing children in thedental experience.

P i E i


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Pre appointment Experience

Bring child to dental office for a tour and orientation.

Child is made aware that nothing will be done that day.He meets the receptionist, dental assistant and the dentist.If things go well, certain dental equipments can be shown& explained in childese using euphemisms.


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Euphemisms in dentistryDrill- Mr. bumpyExplorer- tooth counter Amalgam- cool,star or princess star Anaesthetic injection- sleepy juiceCaries- tooth bugRadiograph- picture of tooth X-ray machine- cameraFluoride- tooth votaminsProphy angle- awesome tooth brushProphy paste- toothpaste

Rubberdam- raincoat


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AdvantagesIt eliminates any unfavourable imaginings as to the realitiesof dentists office & personnel. Child will be delightful seeing toys in reception & otherchildren having fun.Linguistically, there is a greater likelihood that requests ofthe dentist at the first real appointment will be objectivelydealt with as they will react more favourably to the requestsof familiar persons than strangers.For most children 3 yrs or older first appointment can bemade pleasant and enjoyable by doing an examination,prophylaxis and fluoride treatment only.


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This is not used much anymore due to time constraintsof both parents and dentists.This is different from observational approach in whichchild observes his sibling or parent being treated.In observational appointments children mightbackfire if they see something that frightens them.


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Desensitisation Joseph Wolfe (1975) used to remove fears and tension in children whohave had previous unpleasant dental experience or negative behavior.Reciprocal Inhibition Process by which a person experiencing anxietyin association with a certain stimulus is made to experience a responsethat inhibits anxiety to that same stimulus.

Desensitization is accomplished by teaching the child a competingresponse such as relaxation and then introducing progressively morethreatening stimuli.It is an effective method for reducing a maladaptive behavior.The Technique:-

1) Training the patient to relax.2) Constructing a hierarchy of fear producing stimuli related to the

patients principal fear.3) Introducing each stimuli in the hierarchy in turn to the relaxed patient,

starting with the stimulus that causes least fear and progressing to thenext only when the patient no longer fears that stimulus.


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Technique in its classical form:- Teach the patient how to relax; toinduce a state of deep muscle relaxation. Introduce imaginary scenesrelated to his fears, presented in a graduated fashion so that the scenesonly provoking minimal anxiety are described. Gradually more stressfulsituations are presented. Anxiety is minimized through the use ofrelaxation.Fear of the dental environment in general:- Desensitization includesuccessive introduction of the child to the following stimuli:-

Reception and waiting room Dentist and nurse Dental chair Oralexamination prophylaxisFear of the drill and of the needle: - Selected stimuli may be:-Brushing the childs teeth with a prophylaxis brush held in hand.Brushing with a prophylaxis brush in slow speed hand piece.Using a fine finishing bur in a slow speed hand piece revolving in the

mouth but not in contact with teeth. Applying the finishing bur gentlyto a tooth surface.Desensitization from the needle fear is more difficult, especially with

young children, who cannot be expected to react favorably to the sightof a needle, even less ,to its introduction into their mouth. Somedentist prefer to show the patient the cotton roll with topical anestheticand avoid sight of the needle, while others consider some form ofsedation.

T ll Sh D TSD


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Tell Show Do TSD( Educational technique)

Methods popularly used nowadays for modifying the behavior by desensitization inchildren is Tell-Show-Do technique (TSD) Addleslon (1959) introduced the concept Tell , Show and Do .Tell and show every step and instruments and explain what is going to be doneContinuously and in grades from the least fear promoting object or procedure move tohigher grades to more fearful objects.

Indications : First VisitSubsequent visits when introducing new dental procedureFearful child Apprehensive child because of information received from parents/peers

Objectives: The objectives of tell-show-do are to:1. Teach the patient important aspects of the dental visit and familiarize the patient with the

dental setting.2. Shape the patients response to procedures through desensitization and well -described

expectations.


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TSD Techinque is applied as follows :The dentist using the language that the child can

understand, tells the patient what is to be done (exceptthe injection of L.A. or other procedures that defyexplanation such as pulp exterpation). It is presentedslowly and repeatedly .

The dentist demonstrates the procedures to the childusing a model or himself and is done slowly. The dentist proceeds to do the dental procedureexactly as described.
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E.g. if we are using a prophy angle and rubber cup forpolishing of childs teeth, we will tell him that we areusing a special kind of toothbrush which will rotate when I step on the gas pedal.

Let the child touch the rubber cup to feel how soft it isand run the rubber cup on the nails of the child toshow him how it works. Tell him his teeth will becomeshining after using this.
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Children above 3 yrs can be guided by TSD.Choice of words is important.Dentist should have a substitute vocabulary for his or hertools and procedures that the child can understand.

Advantages:By receiving information by dentist, childs fear of

unknown or anticipation of pain quickly go away.This technique linguistically enhances the chances thatappropriate request by the dentist will be met by anappropriate, effective action on the part of the child.


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Modelling Introduced by Bandura (1969) , developed from social-learning principle,procedure involves allowing a patient to observe one or more individuals(models) who demonstrate a positive behavior in a particular situation.

Therefore the patient will frequently imitate the models when placed in asimilar situation.

Modelling can be done by :1. Live models siblings, parents of child n etc 2. Filmed models3. Posters4. Audiovisual aids


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Modeling serves 4 basic functions:-1. Stimulation of a new behavior.2. Facilitation of behaviors already in the patient in a more appropriate

manner or time.3. Disinhibition of behaviors avoided because of fear.4. Extinction of fears.

Learning through modeling is effective when :Observer is in a state of arousal When the model has relatively more status and prestige When there are positive consequences associated with modelsbehavior.

An important advantage of live modeling is that no additionalequipment, personnel or alterations in the dental routine are required


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Contigency Management It is a method of modifying the behavior of children by presentation or

withdrawal of reinforcers. These reinforcers can be :Positive reinforcer : is one whose contingent presentation increases thefrequency of behavior.Negative reinforcer : is one whose contigent withdrawal increases thefrequency of behavior. Negative reinforcer is usually termination of an aversivestimulus. Negative reinforcement strenthens a behavior because a negativecondition is stopped or avoided as a consequence of the behavior.

Types of reinforcements can be :a) Social: eg : praise, positive facial expression, physical contact by shakinghands, holding hands and patting shoulder on the back.b) Material : may be given in the form of toys , games . Sweets are not given asreward since it causes caries.

c) Activity reinforcers : Involving the child in some activity like watching TVshows.

Objective: To reinforce desired behavior. Indications: May be useful for any patient. Contraindications: None.


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Implosion therapySudden flooding with a barrage of stimuli which haveaffected him adversely and the child has no otherchoice but to face the stimuli until a negative responsedisappears.Implosion therapy mainly comprises of :HOME

Voice controlPhysical restraints


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HOME( Hand Over Mouth Exercise) AAPD recognizes HOME as legitimate with indications andcontraindications.Used to intercept tantrums and other fits of rage.

Technique :Dentist places hand over the mouth of a hysterically crying child.Behavioral expectations are calmly explained close to child's ear.

When the child's verbal outburst is completely stopped and childindicates his willingness to co-operate, the dentist removes hishand.

Whole procedure should not last for more than 20-30 seconds.


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It has to be paired with voice control. Works reliably with a variety of child personality types.It is not intended to scare a child.Should be practiced aversively.It is intended to get the child's attention and quite thechild so that he or she can hear what the dentist issaying.Obviously it reframes the seriousness of a previousrequest.Practice of HOME requires informed consent.


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Indications:Normal child, old enough to understand the directions of the dentist & tocooperate but who exhibits defiant, obstreperous or hysterical avoidancebehaviors to dental treatment.

Contraindications:Practice on disabled, immature or medicated children whose understanding ofthe desires of the dentist is compromised.Prevention of the child from breathing.

Disadvantages:May be psychologically aggravating to the child.No formal study to verify this suspicion. Advantage: This technique works fast and is cost effective.Most practitioners who practice this technique note that they very seldom needto do it.


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HOMAR(airway restricted)The advantage behind airway restriction is that thechild will be quite so as to breathe and the screaming will decrease so that the doctor can proceed.Together with hand over mouth nostrils are pinchedfor 15 seconds.Belanger 1993, believed that airway constriction was

the crucial element and it should be avoided.


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HOME as Linguistic technique When it is not used aversively but rather is practiced asa tap on the lips to remind the child that crying is notappreciated during the dental appointment.HOME used this way, in which there is no airwayrestraint intended at all, it becomes a coachingtechnique and a way of reframing earlier requests to bequite and cooperative.


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Voice control Voice control requires the dentist to interject moreauthority into his or her communication with the child.Tone of voice is important.It must have an I am in charge here ring to it. Facial expression of dentist must mirror this attitude ofconfidence.In fact, a dentist can use voice control with facialexpressions alone.So, voice control can be used with deaf children.It is an essential technique for examining pre school kids.


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Extremely effective at intercepting inappropriate behaviors asthey start to happen and is moderately effective at interceptingthem after they are full blown.

Voice control is a useful way of reframing the request that hasbeen refused by the child.Purely linguistic technique, voice control relies on tonality andcadence & should be understood to have non verbalcomponents.

Objectives: The objectives of voice control are to:1. Gain the patients attention and compliance.

2. Avert negative or avoidance behavior.3. Establish appropriate adult-child roles.

Indications: May be used with any patient.


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Physical RestraintsLast resort for children who are hypermotive, stubborn or defiant(kelly1976).Holding child's hands by dental assistant during injection, stabilizationof leg that was starting to lift from chair by dental assistant orstabilization of shoulder by a dentist as a child starts to roll over, whenpaired with language, becomes part of the entire linguisticmanagement.

This is ontologics coaching.

Advantage:Gentle physical restraints allows the dentist to reframe a previousrequest.

2 types: Active: restraints performed by the dentists, staff or parent without theaid of restraining device.Passive: with the aid of restraining device.

T f t i t


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Types of restraints:For body Pedi wrap

Papoose board

SheetsBeanbag with strapsTowel and tapes

For extremities Velcro strapsPosey strapsTowel and tape

For the head Head positionerForearm body support

For mouth Mouth blocksBanded tongue bladesMouth props Used at the time of L.A. For mentally/physically handicappedchild Young child / fatigued child due tolong appointments who can not keephis mouth open for long time


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Patients under 18 months of age with limited communicative ability are most effectivelytreated with physical restraint.However, the restraint must be administered in a non-traumatic manner.Since children at this age are still very attached to parents, the parent should be activelyinvolved in the restraint wherever possible.The most effective and comfortable position for the patient, parent, and dentist is theknee to knee position.

The dentist and parent sit opposite one another with knees touching. The child sits in thelap of and facing the parent with their legs embracing the parents lap. While the parentis holding the patients hands, the child lays backward with the head resting in thedentists lap. This position enables the child to see and feel the parent while the dentistperforms the examination with minimal restraint. The position allows for excellent visualization of the oral cavity by both the parent and dentist.

An alternative technique is to allow the child to sit in the parent's lap. This positionincreases patient cooperation by increasing the security of the child. Note the parentrestrains the patient's upper body with their arms and hands and the lower body by criss-crossing the legs.


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Praise & Communication

Self explanatory. All people, including children react favorably to praise.Effective dentistry for children means effectivecommunication of the dentist with the child and vice

versa. Both allow for distraction of the anxious child.Language used should be age appropriate.Knowing how to talk to children of different agescomes with experience.


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Voice claritySudden and firm commands are used to get the childs attention or tostop the child from whatever is being done.

Another form of voice control is a slow and deliberate cadence that can

function like music set to a mood.Study by Greenbaum & colleagues showed that compared to normal

voice commands, loud commands reduced disruptive behaviors.

Chambers theory is that voice control is most effective when used inconjunction with other communications.

The same message spoken in a foreign language probably would beequally effective.


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Multisensory communicationNon verbal communication:

Helps children to relax esp. 7-10 years.Body contact by placing a hand on childs shoulder, conveys feeling of warmth & friendship.SmilingExpression of feeling without speaking.Giving a hug or pat. Also, sitting and speaking at eye level allows for friendlier & less authoritativecommunications.

Eye contact- if child avoids eye contact, he is not fully prepared to cooperate.Rapid heart beat, beads of perspiration on face alerts dentist to child'snervousness.


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The 3 essential communications imparted to child patients through

primarily non-verbal means are:1. I see you as an individual and will respond to your needs as such.2. I am thoroughly knowledgeable and highly skilled.3. I am able to help you and will do nothing to hurt you needlessly.

Objectives: The objectives of nonverbal communication are to:1. enhance the effectiveness of other communicative management

techniques.2. gain or maintain the patients attention and compliance.

Indications: May be used with any patient.

Contraindications: None


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Problem ownership :In difficult situations, dentists start sending You messages. E.g. Youmust sit still.

These are negative messages. An alternative is to send I messages. E.g. I cant fix your teeth if youdont open your mouth wide. This is one of the techniques discussed by Wepman and Sonnenberg.

Active listening :Listening to spoken words may be more important in estabilishingrapport with the older child than guiding the behavior of a youngerone.

Appropriate responses :Should be appropriate for situation.Depends primarily on the extent and nature of the relationship withthe child, age of child & evaluation of motivation of childs behavior.


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Other methods1. Maternal anxiety reduction techniques- It has been shown that asmothers anxiety about her childs dental appointment lessens, sodoes her childs anxiety.

2. Pairing a frightened child with a brave child in the clinic has hadsome success.

3. Hypnosis and relaxation techniques- exercises to be practiced for 15minutes at home daily.

4. Play therapy.5. Time out to listen to music or white sound. 6. Desensitization sessions.

7. Giving gifts.8. Observation appointments.9. Humor10. Coping11. Biofeedback


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Audio analgesia or white noise - A method of reducing pain. This technique consists of providinga sound stimulus of such intensity that the patient finds itdifficult to attend to anything else.(Gardner, Licklinder, 1959).

Auditory stimulus such as pleasant music has been used toreduce stress and also reduce the reaction to pain.

Biofeedback-Involves the use of certain instruments to detect certainphysiological processes associated with fear(Buonomono, 1979)

E.g.- if blood pressure is high the instrument gives stimulationand the subject is taught to control the signals, therefore it isuseful in anxiety and stress disorders. Electroencephalogram,electromyography can also be used in bio-feedback.


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Humor

Helps to elevate the mood of the child, which helps the child torelax.

Functions of humor:Social: forming and maintaining a relationship.Emotional: anxiety relief in the child, parent and doctor.Informative: transmits essential information in a non-threatening way.

Motivation: it increases the interest and involvement of thechild.Cognitive: distraction from fearful stimuli.


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CopingMechanism by which child copes up with the dental treatment.It is defined as the cognitive and behavioral efforts made by an individual to master,tolerate or reduce stressful situations(Lazaue 1980).Patients under stress prefer to draw comfort from an authority figure. Thus establishing aclose or trusting relationship with the doctor or nurse.

Coping effects may be of two types:1. Behavioral: physical and verbal activities in which child engages to overcome a

stressful situation.2. Cognitive: the child may be silent and thinking in his mind to keep calm. This enables

children to:Maintain realistic perspective on the events at hand( reality-oriented working)Perceive the situation as less threatening(cognitive reappraisal)Calms and reassures themselves that everything will be all right( emotional regulatingcognitions)(Sandra L Curry, 1988).

The normal coping mechanism utilized by dentists to reduce pain and tension arefriendliness, support and reassurance.

Signal system: as a part of coping, when it hurts, child is asked to raise his hand assuggested by Musslemann 1991.


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The non verbal advantage to child

patient managementThe request or re- request of the dentist in the domain called voicecontrol implies that there is a body posture (a place) that may or maynot be entirely visible to the child but that takes the dentist to a placefrom which the dentist can speak with authority, command & selfconfidence.

This place allows the experience of a non verbal advantage. This meansthat the clinician is in posture & state of body control that empowershis or her coaching of the child patient.

HOME is favorably enhanced by the non verbal advantage.

Effective HOME would be impossible without effective voice control, &effective voice control is probably impossible without the non verbaladvantage.


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The PlaceThe dentist should be looking at the child in a downward andforward position of his/her body.

Clinicians who notice deterioration of behavior in a posture in which they are largely behind the child generally move to aposition from which there is frontal facial posture available forthe child to see expressions & to have eye contact.

The leaning downward and forward dramatizes to the child non verbally that the original requests of the clinician are important.

The posture has positive effect on the confidence of dentist.

Once mastered, the clinician will reflexely go to the posture of

downward and forward.


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Your attitude and postural dynamics - by Dr. Heller,summarizes how body position affects attitude.

Attitudes

1. Grounded, decisive,powerful & direct.

2. Supportive, caring &

adaptable.3. Dynamic, inspiring &

friendly.4. Thoughtful, peaceful &

perceptive.

Posture

1. Forward & down.

2. Back & down.

3. Forward & up.

4. Back & up.


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Dr. Albert Mehrabian found that during communicationexperience:7% of ones impact from the words that are chosen. 38% from how those words are spoken( tone, volume, pacing).55% from non verbal expressions- movement, posture, gesture &timing.Dr. Heller offers that attitude is a function of the interactionbetween state of mind, feeling & how one carries onself.Mind belongs to body and body belongs to mind.

Mental processes such as worry, anxiety & anger have a profoundphysiological effect on the body.Motion, movement, posture & breathing have dynamic impactson attitudes, emotions & moods.


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Control over body favorably affects such factors as facialexpression & tonality of voice.This is a distinct non verbal advantage and useful predictor

that distinguishes those clinicians who have a knack of working with children.They may have smaller frames, less muscle mass, may havea higher voice, be less articulate, or even suffer from speechimpediment & still be more effective than others who haveoutstanding voice qualities.The non verbal advantage is a bodily advantage thatempowers the clinicians during communication process ofmaking requests to the child patient.


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Experimental mastery:It relates to the person who has with conviction tried to find thenon verbal advantage & has looked for that place in whichhis/her request or re-request has the strongest design and the

greatest impact on the child.Clinician should access this place spontaneously and reflexely.

Mastery:

Dentists who experimentally practice with a non verbaladvantage.They are mostly older, have obtained great rewards from it &they do not think that it has long term side effects.


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Mastering the non verbal

advantageDr. Stuart Heller- stages of learning child patient management.Shift in

language/movement

pattern

Shift in actionpath, action

initiative &action result

Shift in set

of possibleactions

Shift in tone

ofexpression

Shift in yourpresence An informed

observer can see it

You feel it others cannot see it.

In the beginning there is change in students own confidence & movement


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g g gpatterns, posture, walking, concentration and emotion.

Next, the clinician will start to have confidence about his/her competence inbehavior management domain & is starting to feel comfortable around the

children.In early stages only the clinician will know that this is happening.

At some point the confidence of clinician becomes apparent & the movementpatterns more sophisticated. At this point an informed observer can see theapproached being used.

Next, clinicians movement & body patterns become appropriate for thechallenges at hand.

The clinician now can take effective actions with the child that were impossiblebefore.

Finally the shift in possible actions allows the clinician to work with maximalefficiency allowed by non verbal advantage.

Linguistically, he/she has gained the advantage of making powerful requests &re-requests.


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Behavior shapingBased on the established principles of social learning.Def: it is that procedure which very slowly develops

behavior by reinforcing successive approximations of thedesired behavior until the desired behavior comes to be.

According to this theory most behavior is learned &learning is the establishment of a connection between a

stimulus & a response. It is sometimes called stimulusresponse theory.


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Outline for behavior shaping model

1. State the general goal or task to child at the outset.2. Explain necessity for procedure.3. Divide the explanation for procedure.4. Use euphemisms & give explanations at the childs level of understanding. 5. TSD technique should be used by all members of dental team. Only when

the child has a veiw of the procedures being undertaken successiveapproximations being performed properly.

6. Reinforce appropriate behavior. Clinical research of Weinstein et al showedthat immediate and specific reinforcements were most consistently followedby reductions in childrens fear -related behaviors.

7. Disregard minor inappropriate behavior. It will extinguish itself when it isnot reinforced.

TSD & behavior shaping differs as behavior shaping also includes the need toretrace steps if misbehavior occurs.


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RetrainingFor children displaying considerable apprehension or negativebehavior. May be result of previous dental visit, or effect ofimproper parental or peer orientation.

Determine the source of problem.

Objective is to built a new series of associations in the childsmind.

E.g. if the childs expectation of being hurt is not reinforced, a

new set of expectations is learned, dentist can be trusted.To offset the stimulus generalization, dental team mustdemonstrate a difference. E.g. - use of NO-Oxygen sedationoften works when retraining children. It offers a difference.


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Practical considerations

1. Scheduling :Lacking the patience of adults, many children become restless& tired when faced with long delays in a reception area.

Morning appointments are preferred as children are more alertand dental team is fresher.

When age groups are kept together, the peer group has apositive influence, with children serving as models for eachother. Also dental office may run more smoothly with lesspsychological change of pace.

Appointment length should not be excess of 30 minutes, aslonger the appointment time, greater the likelihood of a stress-fear reaction.


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2. Parent - child separation :

Objectives:The objectives of parental presence/absence are to:1. Gain the patients attention and improve compliance. 2. Avert negative or avoidance behaviors.3. Establish appropriate dentist-child roles.4. Enhance effective communication among the dentist, child, and

parent.5. Minimize anxiety and achieve a positive dental experience.

Indications:May be used with any patient.

Contraindications:Parents who are unwilling or unable to extend effective support (when

asked).


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Advantages of parent in reception room:

Improved interaction between dentist and child.Development of positive behavior on the part of child.Prevents parental interference.Dentist may be more relaxed and comfortable.

Advantages of parental presence with child:

Would reassure both parent and the child.Informed consent can be taken alongside procedures.Parents can witness dentists compassionate approach, & can hear theeducational instructions given to the child.

Dentist obtains rapid feedback on parental attitudes and beliefs.Supporting and communicating with a disabled child.Children upto 3 and half to 4 years of age benefit most from parental presence.


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3. Tangible reinforcements :

Gift giving practice can have spectacular results.

Finn made the following distinction between rewards and bribe. A bribe is promised to induce behavior, a reward is recognitionof good behavior after completion of the operation, withoutpreviously implied promises.

D l H


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Dental HomeThe AAP endorsed the concept of one-year dental visits in 2003 and introduced

the policy to AAP members in the May 2003 issue of Pediatrics.The policy statement recommends an oral health risk assessment by 6 monthsof age and the establishment of a "dental home" for all infants by 12 months.

The risk assessment can be performed by a qualified pediatrician or otherpediatric health care professional.

Infants requiring treatment at 6 months of age and thereafter all infants at 12months are referred to a "dental home," or, dentist.

The concept for the dental home is derived from the AAP's "medical home.

The AAP states, "Pediatric health care is best delivered where comprehensive,continuously accessible and affordable care is available and delivered andsupervised by qualified child health specialists."

The AAP recommends that pediatric primary dental care be delivered in asimilar manner.


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Information about proper care of the childs teeth and gingival. This would include the prevention, diagnosis and treatment of disease ofthe supporting and surrounding tissues and the maintenance of health,function and esthetics of those structures and tissues.

Dietary counseling

Referrals to dental specialists when care cannot directly be provided within the dental home.

Education regarding future referral to a dentist knowledgeable andcomfortable with adult oral health issues for continuing oral healthcare; referral at an age determined by patient, parent and pediatricdentist.

This policy presents a great opportunity to prevent dental disease in the youngest population.


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ConclusionThere are a variety of behavior management techniquesavailable. Depending upon the age, emotionaldevelopment and legal considerations, appropriatetechniques should be used for child management. Behavior management is based on scientific principles. The

proper implementation of behavior modificationtechniques requires an understanding of these principles.It is more than pure science and requires skills incommunication, empathy, coaching, and listening.The goals of behavior management are to establish

communication, alleviate fear and anxiety, deliver qualitydental care, build a trusting relationship between dentistand child, and promote the childs positive attitude towardoral/dental health and oral health care.


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The urgency of the childs dental needs must be considered when planning treatment. Deferral or modification of treatmentsometimes may be appropriate until routine care can beprovided using appropriate behavior modification techniques.

All decisions regarding use of behavior modification techniquesmust be based upon a benefit vs. risk evaluation. As part of theprocess of obtaining informed consent, the dentistsrecommendations regarding use of techniques (other thancommunicative guidance) must be explained to the parentsunderstanding and acceptance. Parents share in the decision-making process regarding treatment of their children.


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References1. Textbook of pedodontics by Shobha Tandon.1 st ed. pp-140-153.2. Dentistry for the child and adolescent by Mc Donald and Avery. 9 th

ed. pp-27-40.3. Pediatric dentistry- infancy through adolescence by Pinkham. 4 th ed.

pp-394-412.

4. J.F. Roberts, M.E.J. Curzon, G. Koch, L.C. Martens. Review:Behaviour Management Techniques in Paediatric Dentistry.European Archives of Paediatric Dentistry 2010. 11: 166-174.

5. Guideline on Behavior Guidance for the Pediatric Dental Patient.Clinical guidelines by AAPD.

6. Basic Techniques for Management of the Infant and Toddler Patient

by Steven Schwartz.7. Vijay Parashar . Parental Presence During Their Childs DentalTreatment. J Oral Health Comm Dent 2010; 4:52-54

8. Robyn Ridley-Johnson, Barbara G. Melamed. Behavioral methodsand research issues in management of child patients. AnesthesiaProgress 1986; 17-23


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Modification of Child's Behavior

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