Behaviour Science and its Application in Pediatric Dentistry

Definitions
Behaviour: any change observed in the functioning of an organism Behaviour science: the science which deals with the observation of behavioural habits of man and lower animals in various physical and social environments; including behaviour pedodontics, psychology, sociology and social anthropology. Behavioural pedodontics: study of science which helps to understand development of fear, anxiety and anger as it applies to child in the dental situations. Behaviour management: means by which the dental health team effectively and efficiently performs dental treatment and thereby instills a positive dental attitude. (Wright, 1975) Behaviour modification: attempt to alter human behaviour and emotion in a beneficial way and in accordance with the laws of learning

Classification of childs behaviour observed in dental clinic

A. Wilson (1933) 1. Normal/ bold: brave, cooperative and friendly with dentist 2. Tasteful/ timid: shy but not interfere with the dental procedure 3. Hysterical/ rebellious: throws temper tantrums, rebellious 4. Nervous/ fearful: tense and anxious. Fear dentist B. Frankels behavior rating scale (1962) Behaviour Definitely negative Rating 1 Symbol (--) Features Refuses treatment Cries forcefully Extremely negative behaviour associated with fear Reluctant to accept treatment Displays evidence of slight negativism

Negative

(-)

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Positive

(+)

Definitely positive

(++)

Accept treatment. Child gas a bad experience during treatment may become uncooperative Unique behaviour. Look forward ti and understands the importance of good preventive care.

C. Lampshire (1970) 1. Cooperative: physically and emotionally relaxed. Cooperative throughout the entire procedure. 2. Tense cooperative: tensed and cooperative 3. Outwardly apprehensive: avoids treatment initially, accepts dental treatment eventually. 4. Fearful: requires considerable support so as to overcome the fears of dental treatment. 5. Stubborn/ defiant: passively resists treatment. 6. Hypermotive: agitated, screaming, kicking 7. Handicapped: physically/ mentally, emotionally handicapped 8. Emotional immature D. Wright (1975) 1. Cooperative ( positive bahaviour) a. Cooperative behaviour: cooperative and relaxed b. Lacking cooperative ability: 0-3 yrs, disable child. Physical and mental handicap. c. Potentially cooperative: has the potential to cooperate. Due to ingerent fear the child does not cooperate 2. Uncooperative ( negative behaviour) a. Uncontrolled/ hysterical/ incorrigible : preschool; temper tantrums b. Defiant bahaviour/ obstinate behaviour: any age group, spoil/ stubborn children c. Tense cooperative d. Timid behaviour/ shy: overprotected child; shy but cooperative e. Whining type: complaining type of behaviour f. Stoic behaviour: physically abused children

E. Garcia Godoy (1986) 1. Fearful 2. Timid 3. Spoiled 4. Aggressive 2|Page

5. Adopted 6. Handicapped 7. Cooperative

Factors which affects childs behaviour in the dental offices

Under the control of the dentist 1. Effects of dental office environment 2. Effects of dentists activity and attitudes 3. Dentists attire 4. Presence/ absence of parent in the operatory 5. Presence of an older sibling Out of control of the dentist 1. Growth and development 2. Nutritional factors 3. Past dental experiences 4. Genetics 5. School environment 6. Socioeconomic status Under the control of the parents 1. Home environment 2. Family development and peer influence 3. Maternal behaviour

Under the control of dentist

1. Dental clinic: a. Warm and simulate homely environment b. Colourful, lively with poster, TV and video games, toys, comics and story books c. Separate exit and an entry door d. Appointment time should be short, < 30 minutes; early morning appointment e. No long appointment are given to children -> deterioration of bahaviour f. Preparation of the children done by telephone/ letter/ pamphlets

2. Effect of dentists activity and attitude a. Data gathering and observation: Collection of info by formal/ informal office interview/ written questionnaire Observation: noting the dental office during history taking and while the dental procedure is being carried out b. Structuring: establishing certain guidelines of behaviour set by the dentist and his team to the child c. Externalization: childs attention is focused away from the sensation associated with dental treatment by 3|Page Distraction Involvement

d. Empathy and support :capacity to understand and to experience the feeling of other e. Flexible authority: compromises made by dentist to meet the need of the particular patient f. Education and training: implement a program which both educated children and their parent 3. Effect of dentists attire: mere present of white clothes individual would evoke a negative baheviour. 4. Presence or absence of parent in the operatory: a. Mothers presence is essential for a preschool child, handicapped child.

b. Older child does not require mothers present because of emotional independence of these children. 5. Presence of an older sibling: as a role model. Most noticeable among 4 years old.

Out of control of the dentist

1. Growth and development: deficiency in physical growth and development / congenital malformations. a. Eg: cleft lip -> physiological trauma due to rejection of the society b. Mental retardation, epilepsy, cerebral palsy child -> cannot react to the requirements of the mother and the expectation of the society 2. Nutritional factors a. Sugar -> irritable behaviour b. Hypoglycemia -> criminal behaviour c. Skipping breakfast -> impair performance d. Nutrional deficiency affects the milestone of biological + cognitive development 3. Genetics a. Psychological development b. Modified by environment 4. Past medical and dental experience: past unpleasant dental experience assoc. with a high degree of uncooperative behaviour 5. School environment: teacher and peer influence the bahaviour of the younger children. Senior -> role model to the junior. 6. Socioeconomic status: a. High social economic status: develop normally

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b. Low socioeconomic status: resentment, tensed ; child get little attention and is often neglected.

Under the control of the parents

1. Home environment: all the home individuals ( especially mother) influence the childs behaviour 2. Family development and peer influences: a. Position of the child, status of the child in the family, parental attitude can influence the childs behaviour b. Overindulgence -> spoil behaviour -> outbursts and temper tantrums. 3. Maternal behaviour: a. Somatic development of the fetus depends on the nutritional status of the mother b. Neurohormonal system of mother transfer emotion to the fetus. c. Postnatal behaviour linked to emotional status if the expectant mother. d. Agent ( alcohol, smoking and keratogenic/ totipotent drugs affect the childs development if consumed during pregnancy

Maternal influences on personality development

1. Over protective mother a. Close relationship btw the mother and the child b. Physical and emotional dependence from birth to 4yrs c. Causes of overprotection: Mothers which have conceived a child after a long time Oly child Sick child/ handicapped child Financial reasons d. Features Not permitted to use his initiative/ make decisions for himself Mother takes active part in his social activities Child is submissive, shy, anxious and fears new situation Lack in self confidence e. Management Create self confidence in the child 5|Page

 Familiarize the child with the clinic and the dentists auxiliaries Tell show do technique 2. Overprotective overindulgent mother a. Features: Aggressive, demanding, displays temper tantrums Obstinate, stubborn, spoil Demonstrate angry outburst if their demands are not met with 3. Underaffectionate mother a. Child is devoid of love and care b. Varies from mild detachment to neglect c. Causes: Unwanted child Child birth not anticipated Hampers the mothers career and ambitions Unhappy mother because of absent of father due to death/ divorce Lack attention Emotional problems d. Feature : Well behaved and well adjusted Shy Difficult to establish a good rapport Uncooperative to dental treatment 4. Rejecting mother a. In the form of physical violence or verbal ridicule b. Neglect manifest as: Physical punishment Refusal of spend time with the child Refusal to spend money on child Neglect of childs heath\emotional and physical neglect c. Features Over reactive, revolting, aggressive, disobedient Try to gain attention 6|Page

 Constantly criticized, nagged Lack of self esteem d. Management Develop confidence in the child by showing love and care Meet their demands asap. 5. Authoritarian mother a. Mother is very authoritarian b. Features: Submission with resentment and later evasion Evasive, dawdling child, obeys commands slowly/ with delay Parent not supportive rather criticize Mothers behaviour Overprotective dominant Overindukgent Underaffectionate Rejecting authoritarian Childs behaviour Shy, submissive, anxious Aggressive, demanding, display of temper tantrums Well behaved, but maybe unable to cooperate, shy cry easily Aggressive, overacting, disobedient, evasive and dawdling

Classification of behaviour management

A. Non pharmacological (psychological approach) 1. Communication 2. Behaviour shaping (modification) a. Desensitization b. Modeling c. Contingency management 3. Behaviour management a. Audio analgesia b. Biofeedback c. Voice control d. Hypnosis e. Humour 7|Page

f.

Coping

g. Relaxation h. Implosion therapy i. Aversion conditioning

B. Pharmacological methods of behaviour management 1. Premedication a. Sedatives and hypnotics b. Antianxiety drugs c. Antihistamines 2. Conscious sedation 3. General anesthesia

Communicative management
Types 1. Verbal communications by speech 2. Non verbal (multisensory communication) by a. Body language b. Smiling c. Eye contact d. Expression of feeling without speaking e. Showing concern f. Touching the child

g. Giving him a pat h. Hug 3. Using both verbal and non verbal How to communicate Communication should be comfortable and relaxed Language should express pleasantness, friendship and concern Voice should to constant and gentle Tone express empathy and firmness Pt prefer to be addressed by his name

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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Compliment about his appearance Sitting and speaking at the eye level allows for a friendlier atmosphere Use of euphemisms : substitute words used in the presence of children 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Word substitute Wind Pudding, mashed potatoes Sleepy medicine / water Brush/ pencil Brown spot/ sugar bug Tooth counter Vacuum cleaner Fence for filling Raincoat Ring for the tooth Hat for the tooth Camera Picture Whistling train

Dental terminology Air Impression material Anesthetic Bur Caries Explorer Evacuator Matrix Rubber dam Stainless steel band Stainless steel crown X ray Radiograph handpiece Reframing:

Definition: taking a situation outside the frame that up to that moment contained the individual in different conditions and visualize (reframe) it in a way acceptable to the person involved and with this reframing both the original threat and the threatened solution can be safely abandoned. (Peretz 1999)

Behaviour shaping (modification)

Use of selected reinforcers that change a childs behaviour from an inappropriate to an appropriate form Based on the stimulus response theory Technique : a. Desensitization ( tell show do) b. Modeling c. Contingency management Desensitization (Joseph Wolpe, 1975) Teaching the child a competing response , such as teaching and introducing progressively more threatening stimuli

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Tell show do technique: Addleslon 1959 Tell and show every step and instrument and explain what is going to be done Effective in children more than 3 yrs of age Objectives 1. Teach the pt aspects of dental visit, familiarize him with dental setting 2. Shape pts response Indications 1. First visit 2. Subsequent visits when introducing new dental procedure 3. Fearful child 4. Apprehensive child Tell 1. Verbal explanations of procedures in phrases appropriate to the development level of the child 2. Tell the child before, while and after 3. Voice should be soft, firm, comfident and continous 4. Should be truthful with the child Show 1. Demonstrate for the pt of visual, auditory, olfactory and tactile aspects of the procedure 2. Demonstrate to the child what will happen, how and with what equipment 3. Avoid showing fear promoting instruments (anesthesia syringe) 4. Bringing equipment from behind the child/ below the visual level is preferred. Do 1. Without deviating from the explanation and demonstration

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Modeling Bandura 1969 Develop from social learning principle Allowing a pt to observe one or more individuals (models) who demonstrate a positive behaviour in a particular situation. Type 1. Live models: siblings, parents of child 2. Filmed models 3. Posters 4. Audiovisual aids Advantages 1. Patients attention obtained 2. Designed behavior is modeled 3. Physical guidance of desired behavior 4. Reinforcement of guided behaviour Objective 1. Stimulate acquisition of new behaviour 2. Facilitating the behaviour already in the patients in a more appropriate manner 3. Elimination of avoidance behaviour 4. Extinction of fear Learning through modeling is effective when 1. Observer is in a state of arousal 2. When model has relatively more status and prestige 3. When there are positive consequences associated with models behaviour Contingency management Modifying the behaviour of the children by presentation or withdrawal of reinforces. 11 | P a g e

 It can be Positive reinforcer : contingent presentation increase the frequency of behaviour Negative reinforcer: contingent withdrawal increase the frequency of behaviour

Type 1. Social : praise, positive facial expression, physical contact by shaking hand, holding hand and patting shoulder/ back 2. Material : toys, games 3. Activity reinforcer : watching TV show/ special programmes

Behaviour management
Audio analgesia / white noise Methods of reducing pain Providing sound stimulus of such intensity that the patient finds it difficult to attend to anything else Auditory stimulus = pleasant stimulus

Biofeedback Humor Help to elevate the mood of the child Functions: a. Social: forming and maintaining a relationship b. Emotional: anxiety relief c. Informative: transmits essential info in a non threatening view d. Motivation: increase interest and involvement of the child e. Cognitive: distraction from fearful stimuli Involved use of certain instruments to detect certain physiological processes assoc. with fear

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Coping Cognitive and behavioral efforts made by an individual to master, tolerate/ reduce stressful situation Type: a. Behavioral: physical and verbal activities b. Cognitive: child maybe silent/ thinking in his mind to keep calm, enable the children to Maintain realistic perspective on the events at hand Perceive the situation as less threatening Calms and reassures themselves Voice control Modification of intensity and pitch of ones own voice in an attempt to dominate the interaction btw dentist and the child Used in conjunction with physical restrainer/ HOME Change in tone from gentle to firm is effective in gaining the childs attention and reminding him that dentist is an authority figure to be obey Objectives: a. Gain pts attention b. Avoid negative/ avoidance behaviour c. Established authority Indications: uncooperative and inattentive pt Contraindications: age, disability, mental/ emotional immaturity

Relaxation Reduce stress and is based on the principle of elimination of anxiety

Hypnosis Definition: a state of mental relaxation and restricted awareness in which subjects are usually engrossed in their inner experiences Uses a. Reduce nervousness and apprehension b. Eliminate defense mechanism c. Control functional/ psychosomatic gapping

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d. Prevent thumb sucking and Bruxism e. Induce anesthesia Technique

hypnotic induction: focus the subjects's attention ; give repeated instruction; coupling of focussing and suggestion

patient preparation

deepening

altering patient after therapy

post hynoptic suggestion

Implosion therapy Sudden flooding with a barrage of stimuli -> affected the pt adversely -> no other choice but face the stimuli -> negative response disappears Aversive conditioning 2 common methods: a. HOME b. Physical restraint HOME (hand over mouth exercise) Evangeline Jordan 1920 Aka aversive conditioning, emotional surprise therapy, hand over mouth technique and aversion by Crammer Objectives 1. To gain childs attention 2. Eliminate inappropriate avoidance 3. Increase childs confidence 4. Assure child safety in delivery of quality dental care Indications 14 | P a g e

1. Healthy child able to understand exhibit defiant hysterical behaviour 2. 3 6 yrs 3. Child who can understand simple verbal commands 4. Children displaying uncontrollable behaviour Contraindications 1. Child under 3 years of age 2. Handicapped child/ immature child, frightened child 3. Physical, mental and emotional handicap 4. When it prevents child from breathing 5. When dentist emotionally involved with the child Technique 1. Firmly place hand over childs mouth -> behavioural expectation explained -> childs outburst is completely stopped + willingness to cooperate -> hand remove2. 2. Childs airway is not restricted 3. Whole procedure not last for more than 20 30 seconds Variations 1. Hand over mouth with the airway unrestricted 2. Hand over mouth airway restricted ( HOMAR) child will be quiet so as to breath screaming will decreased hand over mouth, nose pinched for 15s 3. Towel held over the mouth only 4. Dry towel held over the nose and mouth 5. Wet towel held over the nose and mouth Physical restraints Types A. Active/ passive a. Active: restraints performed by dentist, staff/ parent w/o the aid of a restraining device 15 | P a g e

b. Passive: aid of restraining device B. Based on part of the body restraint a. For body Pedi wrap Papoose board Sheets Beanbag with straps Towel and tapes b. For extremities Velcro straps Posey straps Towel and tape c. For the head Head positioned Forearm body support d. Mouth Mouth blocks Banded tongue blades Mouth props e. Others Strap Sheets Indications 1. Lack of maturity 2. Mental or physical disabilities 3. Does not cooperate after other behaviour management technique have failed 4. Safety of the pt/ practitioner would be at risk w/o the protective use of immobilization Contraindications 1. Cooperative patient 2. Pt who cannot be safely immobilized because of underlying medical/ systemic conditions 16 | P a g e

3. As punishment 4. Not used solely for the convenience of the staff

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