Non –pharmacological behavior management in children

Overview on nonpharmacological managent of behaviour in children
Presented by : Mayuri Karad
SDDCH Parbhani
Guided by : Dr. Rehan Khan
Dept, of Pediatric and preventive dentistry

1. NON –PHARMACOLOGICAL BEHAVIOR MANAGEMENT PRESENTED BY – MAYURI KARAD

2. DEFINITION -BEHAVIOR -BEHAVIOR MANAGEMENT -BEHAVIOR SHAPING -BEHAVIOR MODIFICATION CLASSIFICATION NON-PHARMACOLOGICAL BEHAVIOR MANAGEMENT -COMMUNICATION -USE OF SECOND LANGUAGE(EUPHEMISMS) -TELL-SHOW-DO CONTENTS

3. -DESENSETIZATION -MODELING -BEHAVIOR SHAPING -CONTINGENCY MANAGEMENT -EXTERNALIZATION -DISTRACTION -ASSIMILATION AND COPING -PARENTAL PRESENCE OR ABSENCE -RETRAINING -VISUAL IMAGERY -FLOODING TECHNIQUE -VOICE CONTROL -USE OF POETRY AND DRAWINGS -HYPNOSIS -HAND OVER MOUTH TECHNIQUE -PROTECTIVE STABILISATION

4. BEHAVIOR- Behavior is any activity that can be observed , recorded and measured. BEHAVIOR MANAGEMENT- Behavior management is the means by which dental health team effectively and efficiently performs treatment for a child and at the same time instills a positive dental attitude.(WRIGHT,1975) BEHAVIOR SHAPING- It is the procedure , which slowly develops behavior by reinforcing a successive approximation of desired behavior until desired behavior comes into being . DEFINITION

5. BEHAVIOR MODIFICATION It is defined as the attempt to alter human behavior and emotion in a beneficial manner according to laws of modern learning theory.(EYSENCK,1964)

6. NON-PHARMACOLOGICAL(PSYCHOLOGICAL APPROACH ) - COMMUNICATION - USE OF SECOND LANGUAGE -TELL-SHOW-DO - DESENSITIZATION -MODELING -BEHAVIOR SHAPING -CONTINGENCY MANAGEMENT -EXTERNALIZATION -DISTRACTION -ASSIMILATION AND COPING -PARENTAL PRESENCE OR ABSENCE -RETRANING -VISUAL IMAGERY CLASSIFICATION OF BEHAVIOR MANAGEMENT

7. - FLOODING TECHNIQUE -VOICE CONTROL -USE OF POETRY AND DRAWINGS -HYPNOSIS -HAND OVER MOUTH TECHNIQUE -PROTECTIVE STABILISATION PHARMACOLOGICAL MANAGEMENT - PRE-MEDICATION -CONSCIOUS SEDATION -GENERAL ANESTHESIA

8. COMMUNICATION - Communicative management is universally used in pediatric dentistry with both the cooperative and uncooperative child (chambers,1976) -By involving in conversation, the dentist not only learns about the patient but may also relax the patient -Types of communication : 1. Verbal communication by speech 2. Nonverbal communication -Expressions without words like hand shaking , eye contact , smiling 3. Both verbal and non verbal N0N PHARMACOLOGICAL BEHAVIOR MANAGEMENT

9. - communication should be comfortable and relaxed. Communication with children aged 3 to7 years should be based on Piagetian concept which involves life like name to dental instruments like handpiece called whistling Charlie. -The most important aspect of communication is getting the child to respond to dentist’s command. -The three most important facets of communication are source, medium and receiver . In reference to dentistry , dentist is the source , dental clinic is the medium and child is the receiver . - If the dentist is good , sympathetic , confident and honest ; dental is neat ,quiet , familiar to children ,full of toys; the automatically child is communicating and is well managed.

10. USE OF SECOND LANGUAGE (EUPHEMISM) - Euphemisms are substitute words, which can be used in the presence of child . -The dental staff as well as dentist should oriented to the use of second language . DENTAL TERMINOLOGY WORD SUSTITUTE Air - Wind Anesthetic - Sleepy medicine or sleepy water Bur - Brush or pencil Impression material - Pudding or mashed potatoes Caries - Brown spot : sugar bugs Matrix - Fence for filling Rubber dam - raincoat stainless steel crown – Hat for tooth X – ray - Camera Radiograph - picture Handpiece - Whistling train

11. TELL – SHOW- DO -Tell- show –do(TSD) , the cornerstone of behavior management was given by Addleston in 1959. - Specifically , the dentist tells the child what is going to be done in words the child can understand .Second , the dentist demonstrates to child exactly how the procedure will be conducted . Finally ,practitioner performs the procedure exactly as it was described and demonstrated . - Objectives : - To teach the patient aspect of dental visit and to familiarize him with the dental settings. - to shape the patients response to various procedures. - TELL : Tell the child before you do it, while you are doing it and after you have done it . You voice should be soft , yet firm , confident , and continuous .You should be truthful with the child and if the procedure is going to be painful or uncomfortable , say so.

12. Show : - Demonstration of the visual , auditory, olfactory and tactile aspect of the procedure in a carefully defined, nonthreatening setting - The dentist can either demonstrate on himself or an inanimate object. -The noise of running handpiece shows the child through the hearing medium . A pinch on the arm before anesthesia administration demonstrate to the child how the pinch of the injection in the mouth might feel. - Bring equipment from behind the child or the visual level is preferred.

13. DO : - With0ut deviating from explanation and demonstration dentist perform the previewed operation . -In doing, do what you said you would do. - Do not do until the child has clear awareness of what it is you are going to do.

14. - This technique was demonstrated by James and popularize by Wolpe. - It means take away ones sensitivity to a type of behavior. - This is used in children having pre-established fears and uncooperative behavior . - Desensitization accomplished by teaching the child a competing response such as relaxation and then introducing progressively more threatening stimuli. - Is an effective method for reducing maladaptive behavior . DESENSITIZATION

15. - Introduced by Bandura ( 1969). - It is based on one’s learning or behavior acquisition occurs through observation of suitable model performing specific behavior. - Synonyms : imitation , observational learning , identification, internalization , coping . - Modeling seems to improve of the apprehensive child who have had no previous dental experience . - Types of modeling: 1. Audiovisual 2. Live modeling by parents , sibling etc . MODELING

16. OBJECTIVES OF MODELING: Stimulates acquisition of new behavior . facilitating the behavior already in the patients in more appropriate manner. Elimination of avoidance behavior . Extinction of fear. ADVANTAGES OF MODELING: Patient’s attention is obtained. Designed behavior is modeled. Physical guidance of the desired behavior. Reinforcement of the desired behavior ;

17. - It is defined as a process which slowly develops a behavior by reinforcing successive approximation of the desired behavior until the desired behavior is expressed ( Lenchner and wright ,1975) - It is based on stimulus- response theory. - when shaping the behavior the dentist is teaching to a child to behave . BEHAVIOR SHAPING

18. - The presentation of positive reinforcers or withdrawal of negative reinforcers is termed contingency management. - It include : - Positive reinforcement - Negative reinforcement - Omisssion or time out - Punishment Positive reinforcement – is one whose contingent presentation increases the frequency of behavior ( Henry W Fields ,1984) Negative reinforcement – is one whose contingent withdrawal increases the frequency of behavior ( Stokes and Kenndy ,1980) . CONTINGENCY MANAGEMENT

19. - Types of reinforcers = Social – e.g. , praise , positive facial expression , physical contact by shaking hand , hug ,pat on shoulder Material - may be given in the form of games ,toys. Activity reinforcers – Involving child in some activity like watching TV shows , visit to park.

20. - It Is the process by which child’s attention is focus away from the sensation associated with dental treatment by involving in verbal or dental activity. Objectives : - To decrease perception of unpleasantness - to interest and involve children . EXTERNALIZATION

21. - The patient is distracted from the sound and/or sight of dental treatment thus reducing anxiety. - Objective is to relax the patient and to reduce anxiety during treatment. - Use stories and fairy tales. - Use slow instrumental music . - Types of distraction : Audio distraction Audiovisual distraction . DISTRACTION

22. DISTRACTION

23. - Stress can act to increase pain perception while coping decrease it by process called assimilation . - Coping is defines as the cognitive and behavioral efforts made by an individual to master, tolerate or reduce stressful situations (Lazaue ,1980) . - Coping effect may be of two types : 1. Behavioral – are physical and verbal activity in which the child engages to overcome a stressful situation . 2. cognitive - Efforts which involves manipulation of emotions . ASSIMILATION AND COPING

24. OBJECTIVES -To avert avoidance behavior -To establish authority -To gain patient’s attention and compliance -- Advantages of parental absence Overcoming parental conditioning Avoiding communication interference Avoiding parental interference -- Advantages of parental presence Supporting and communicating with the child Very young patients. PARENTAL PRESENCE OR ABSENCE

25. Given by Pinkham in 1985 Sudden and firm commands that are used to get the child attention and stop the child from his current activity Objective 1.attention and compliance 2. To avoid negative or avoidance behavior 3. To establish authority Indications 1. uncooperative and inattentive patients Contraindications 1. Children who due to age, disability, mental or emotional immaturity are unable to understand . VOICE CONTROL

26. - Use of poetry is employed in children above 7yrs of age . - The poem is written as collective effort, the dentist contributing one line and child next. - Use of drawing is useful for children of 3-5 yrs of age . - Child is given a paper and pencil or crayon and ask to draw some picture. Advantages -It allows repetition without monotony . - The rhyme and rhythm can be used to guide the child towards the information to be implied . - It gives the child sense of achievement and increases self esteem. USE OF POETRY AND DRAWINGS

27. - It was first suggested by Franz A Mesmer in 1773 -It is defined as state of mental relaxation and restricted awareness in which subjects are engrossed in their inner experiences such as imaginary are less analytical and logical in their thinking and have enhance capacity to respond to suggestions in an automatic and dissociated manner Uses 1. To reduce nervousness and apprehension 2. To eliminate defense mechanism that patients used to postpone dental work 3.To control functional or psychosomatic gaping 4.To prevent thumb sucking and bruxism 5.To induce anesthesia HYPNOSIS

28. - This technique was first described in 1920 by Dr. Evangeline Jordan Other terminologies : - Aversive conditioning by Lenchner and Wright in 1975 - Emotional surprises therapy by Lampshire - Hand over mouth airway restricted (HOMAR) by Levitas in 1947 - Aversion by Crammer in 1973 Objectives - To gain child attention enabling communication with dentist so that appropriate behavioral expectation can be explained. - To eliminate inappropriate avoidance behavior to dental treatment and to establish appropriate learned responses. - To assure child safety in delivery of quality dental care HAND OVER MOUTH TECHINQUE

29. Indication : A healthy child who is able to understand and cooperate who exhibit defiant , obstreperous or hysterical behavior to dental treatment. Contraindication : Immature child When it prevents child from breathing When the dentist is emotionally involved with child

30. Indication : A patient who requires diagnosis or treatment and cannot cooperate because of lack of maturity. A patient who requires diagnosis or treatment and cannot cooperate because of mental or physical disabilities . When the safety of the patient or practitioner would be at risk without the protective use of stabilization . Contraindication: A cooperative patient As punishment A patient who cannot be safely immobilized because of underlying medical or systemic conditions It should not be used solely for the convenience of the staff . PROTECTIVE STABILIZATION

31. PHYSICAL RESTRAINTS Restraints are usually needed for children who are hyperactive , stubborn or defiant. Types of restraints- a) For body- pedi wrap papoose board sheets Beanbags with straps Towels and tapes b) For extremities- velcro straps posey straps

32. c)For mouth- mouth blocks mouth props - molt mouth prop - rubber bite block - finger guards d) Others – straps are attached to dental unit to restrain a child waist and legs. - sheets used to restrain patients movement. Eg ; papoose board/ pedi wrap.

33. Papoose board Mouth props

34. Proper assessment of children behavior of dentist to plan appointments and render effective and efficient dental treatment. Appropriate use of management techniques can improve the child behavior in subsequent visits. A wide variety of behavior management techniques are available to pediatric dentists which must be used as appropriate for the benefit of each child patient, and which, importantly, must take into account all cultural, philosophical and legal requirements in the country of dental practices of every dentist concerned with dental care of children. CONCLUSION

35. 1) TEXTBOOK OF PEDODONTICS- 2 ND EDITION- SHOBHA TANDON 2) TEXTBOOK OF PEDIATRIC DENTISTRY-3 RD EDITION –NIKHIL MARWAH 3)INTERNET SOURCES REFERENCES