BEHAVIOR MANAGEMENT

By

Dr Nidhi Ravindran

CONTENTS

• INTRODUCTION• DEFINITION• CLASSIFICATION• PHARMACOLOGICAL• NON PHARMACOLOGICAL1. Communication2. Behaviour shaping (modification)

i. Desensitizationii. Modelingiii. Contingency management

3. Behaviour managementi. Audio analgesiaii. Biofeed backiii. Voice controliv. Hypnosisv. Humorvi. Copingvii. Relaxationviii. Implosion therapyix. Aversive conditioning

• BEHAVIOR MANAGEMENT OF CHILDREN WITH HANDICAPPING CONDITIONS• CONCLUSION

INTRODUCTION

The key to successful orthodontic treatmentis a cooperative patient. To achieve thisprerequisite it is of utmost importance todiscover the actions that will produce the mostpositive response from the patient. To determinea child’s behavior in dental office and the factorsinfluencing it we must study a child’s mental andemotional make up that constitute the“psychology” of that child.

DEFINITIONS

PSYCHOLOGY is a branch of science which deals with mind & mental processes in relation to human & animal behaviour.

BEHAVIOR MANAGEMENT is defined as the means by which the dental health team effectively and efficiently performs dental treatment and thereby instills a positive dental attitude (Wright 1975)

BEHAVIOR MODIFICATION: defined as the attempt to alter human behavior and emotion in a beneficial way and in accordance with the laws of learning.

CommunicationTypes:Verbal Communication- SpeechNon verbal / Multisensory CommunicationBody languageSmiling Eye contactShowing concernTouchingPattingHuggingBoth using nonverbal and verbal

DesensitizationIt is accomplished by teaching the child a completing response

such as relaxation and then introducing progressively more threatening stimuli.

Method popularly used nowadays – Tell shows Do (TSD) technique (Addleslon 1959). Tell and show every step and instrument and explain what is going to be done. Continuously and in grades from the least fear promoting object or procedure and move in higher grades to more fearful objects.By having verbal (tell) and nonverbal (show and do) interactions, available, one can overcome many small dental related anxieties of any child.

Modeling 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.

Modeling can be done by:Live models – siblings, parents of a childFilmed modelsPostersAudiovisual aids

Contingency ManagementIt is a method of modifying behavior of children by

presentation or withdrawal of reinforcers.

These reinforcers can be: -Positive reinforcer- whose contingent presentation

increases the frequency of behavior. (Henry W Fields 1984)

Negative reinforcer – whose contingent withdrawal increases the frequency of behavior. (Stokes and Kennedy 1980)

Behavior management

Audio analgesia: or “white noise” is a method of reducing Pain (pleasant music)

This technique consists of providing a sound stimulus of such intensity that the patient finds it difficult to attend to anything else. (Gardner Licklider1959)

b) Biofeedback: It involves the use of certain instruments to detect certain physiological

processes associated with fear (Buonomono 1979). Eg: -electromyography.

C) Humor: It helps to elevate the mood of the child, which helps the child to relax.

Functions of humor are – social, emotional, informative, Motivational, cognitive.

Coping:It is the mechanism by which a 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).

Signal system: In this method as a part of coping, when it hurts, we ask the child to raise his hand as suggested by Musslemann 1991.

e) Voice control: It is the modification of intensity and pitch of one’s own voice in an

attempt to dominate the interaction between the dentist and the child.

Aversive Conditioning

It can be a safe and effective way of managing an extremely negative behavior. Those dentists who contemplate using it should obtain parental consent prior to its use (Patricia P Hagan 1984).

Two Common Methods used are

• Home

• Physical restrains

Hand over mouth exercise (HOME)

The behavior modification method of aversive conditioning is also known as HOME. Introduced by Evangeline Jordan 1920.

The purpose is to gain attention of the child so that communication can be established.

IndicationsA healthy child who can understand but who exhibits defiance and hysterical behavior

during treatment.3-6 year old children.A child who can understand simple verbal commands.Children displaying uncontrollable behavior.

ContraindicationsChild under 3 years of age.Handicapped /immature/frightened child.Physical, mental, and emotional handicap.

PHYSICAL RESTRAINTS

Restraints are usually needed for children who are hypermotive, stubborn or defiant (Kelly 1976).

It involves restriction of movement of the child’s head, hands, feet or body.

It is the last resort for handling uncooperative patients or handicapped patients

It can be

Active – restraints performed by the dentist, staff or parent without the aid of a restraining device.

Passive – with the aid of restraining device

TYPES OF RESTRAINTS

A) For body

Pedi wrap

Papoose board

Sheets

Beanbag with straps

Towel and tapes

For extremities

Velcro straps

Posey straps

Towel and tape

For the head

Head positioner

Forearm body support

Mouth

Mouth blocks

Banded tongue blades

Mouth props

PHARMACOLOGICAL METHOD OF BEHAVIOUR MANAGEMENT

PRE-MEDICATION• Sedatives and hypnotics

• Anti-anxiety drugs

• Antihistamines

• Conscious sedation

• General anesthesia

BEHAVIOR MANAGEMENT OF CHILDREN WITH HANDICAPPING CONDITIONS

Mental Retardation

It affects 3% of the population, is the most common of the handicapping conditions. It may occur solely as an intellectual deficiency, it may be one of a combination of disabilities, or it may be one manifestation of a syndrome (Down’s syndrome).

By definition those who are mentally retarded have a tested intelligence quotient (IQ) of 69 and below.

It is vitally important for the dentist to accept the patient first as an individual and secondly as a patient with a handicap (Album 1962) the practitioner should attempt to discover from the parents and others as much as possible about the child. Parents should be asked how they mange the child.

For patients on the lower curve of the IQ scale the dental chair is positioned before the patient is seated. These patients become easily alarmed when the dental chair is moved.

Since many mentally retarded children have short attention spans, the unmediated child usually does not tolerate lengthy appointments well. Constant patter, television, or audiovisual instruction programs can serve as distracters during treatment procedures.

Adapted behavior modification can be used with many mentally retarded children. (Eg: - body language with the child deficient in verbal skills).

Because mentally deficient children may fail to comprehend they are prone to postoperative soft tissue biting. Ultra short acting local anesthetics should be used. Nitrous oxide sedation benefits some of these patients if they accept the mask.

Major sedation and restraints may be required for some mentally retarded children.

Convulsive Disorders.

Paroxysmal attacks of unconsciousness or impaired consciousness may occur, usually with a succession of tonic or clonic muscular spasms.

The dentist should ask a parent if the child’s seizures are under control and if not, how frequently they occur, when the last seizure occurred and how the parent manages the seizures.

The dentist should contact the child’s physician if the child is taking seizure-control medication. Sometimes an increase in medication dose before a dental visit prevents seizure occurrence.

Care should be taken to avoid inducing seizures. (Hall 1982) suggests that anxiety, intense light and intravascular local anesthesia are seizure triggers. Hall recommends sunglasses to reduce the glare from the operatory light and an aspirating syringe to avoid injection into blood vessels.

A mouth prop consisting of tongue blades wrapped in gauze and heavily taped should be available when treating epileptic children.

In the event of a seizure all instruments should be removed from the mouth immediately. A rubber dam can be used with epileptic children.

A restraining device can also be an asset when treating such patients.Epileptic children should never be left in the operatory unattended.

Cerebral Palsy

The incidence of neuromotor disorders ranges from one to five per 1000 live births (1971). Cerebrakpalsy one of the most common of these conditions, is a CNS disorder manifested by impaired motor function.

While many children with cerebral palsy can walk into the operatory, others are unable to do so. (Parent assistance should be sought).

The dental chair should be preset in the approximate position desired by the operator before the patient is seated.

While examining new patients, the dentist should evaluate their muscle movements carefully. It may be desirable to passively hold a mouth prop, consisting of taped tongue blades, in the oral cavity if there is concern about the patient involuntarily closing the mouth.

Noise making instrument should be avoided if possible as it increases the involuntary contractions of the athetoid patient.

Since these patients have poor control of their orofacial musculature, post operative soft tissue biting can be a problem. Therefore whenever possible the dentist should use ultra short acting anesthetics. Nitrous oxide sedation may help control movements.

Progressive Neuromuscular DisabilityEg: - myotonic dystrophy, muscular dystrophy.

Since these patients may have postural problems. A strap to hold child on the dental chair is frequently appreciated.

To provide realistic treatment plans for these patients, the dentist has to know the prognosis of a child’s condition.

Since dental health is of secondary importance for many of these children, the dental hath team has to be extremely patient and

Deafness

Children with hearing handicaps communicate visually through lip reading. In some instances parents will be required to transmit long complex messages.

Tell show do TSD technique with the following changes is effective with the hearing handicapped :-Remaining in the child’s view to maximize visual communication.Speaking with good lip action to convey information from a distance of about 3 feet.Substituting verbal reinforcement with smiles, squeezing the arm gently etc., to convey the dental

team’s appreciation of a child’s cooperation.Using the tactile sense.

Because the deaf children can be very impatient with delays, an organized plan of procedure is of paramount importance.

For older children “magic slate”, a small chalkboard should be available to enhance communication.The hand mirror is an invaluable aid during most procedures, allowing communication through the

child’s available senses.

Blindness

Non sighted or the partially sighted children must be introduced to foreign environments very slowly.

Constant voice contact should be maintained with the blind children.

The “show” portion of behavior shaping is greatly limited or impossible with blind children. Some of the modification are-increased use of auditory, tactile olfactory and taste senses.

Autism

This condition which manifests itself early in childhood is characterized by certain behavioral traits. These children are unresponsive and uncommunicative, take a greater interest in inanimate objects than in people. Most do not use language properly, and many do not speak at all.

The autistic child usually creates a difficult management problem from the beginning. Repeated visits to the dental office for oral hygiene instruction before examination procedures desensitize autistic children.

A quiet, modulated voice can have a calming effect. Some of them also appear to accept positive reinforcement such as smile or a pat on shoulder.

The autistic child is distracted easily. Therefore only minimal movements should be made during treatment.

Some become calm and highly cooperative with the use of a body restraint, which protects the patient and the dentist.

Since most autistic children do not have medical complications, sedation can be used with minimum risk.

CONCLUSION

A sound knowledge in child psychology and behavior management is essential for a successful practice. Psychology and behavioral sciences have been an integral part of orthodontics both in research and in clinical practice since the early days of this century.

Throughout the course of orthodontic treatment, the orthodontist should keep in mind the fact the psychological outcome of treatment are as important as the occlusal and functional outcomes. Producing an excellent finished result is the primary responsibility of an orthodontist, but producing happy, self-assured patient is an added opportunity. While undergoing orthodontic treatment, the child is expected to follow instruction daily – to wear elastics, head gear, maintain ideal oral hygiene, endure discomfort, keep regular appointments and refrain from eating many foods that can be detrimental to the appliances. Therefore successful child management can only ensure the child to be co-operative, which in turn results in a complete and desired optimal treatment result.