art science of behavior managment

                                                      Pediatric dentistry

Fifth class                                                                         Art science of behavior management

The foundation of practicing dentistry for children is the ability to guide them through their dental experiences. Longer lasting beneficial effects also can result when the seeds for future dental health are planted early in life.
A professional goal is to promote positive dental attitudes and improve the dental health of society.
The purposes of studying child behavior management
1.  To introduce basic information of children behavior.
2. To describe many of the methods used for child behavior management.
Child behavior management defines as that It is the mean by which the dental health team effectively and efficiently performs treatment for a child, at the same time in stills a positive dental attitude. In another words behavior management mean methods used to make the child accept treatment in the dental chair beside educate the child and be sure that he will come a gain for the next appointment.
A major difference between the treatment of children and the treatment of adults is the relationship. Treating adults generally involves a one-to-one relationship, that is, a dentist-patient relationship. Treating a child, however, Usually relies on a one-to-two relationship among dentist, pediatric patient, and parents or guardians. Fig.-l- which illustrates this relationship, is known as the pediatric dentist treatment triangle. Note that the child is at the apex of the triangle and is the focus of attention of both the family and the dental team. 
 

Child development:

 
It involves the study of all areas of human development from conception through young adulthood. All changes occur in size, shape function, structure or skills mean development.
There are several relatively important aspects of child development and no single aspect could be used to assess development because it a multidimensional process. So in order to make accurate information about child s behavior a basic knowledge about child development can help the dentist.

Major areas of development:
 1. Physical development
Any changes that occur with age in children s size, strength, motor coordination and athletic skill beside the growth and changing function of all body systems such as the circulatory, nervous and digestive systems.
2. Social development
That mean as a child grow in his ability to care for himself he gain social independence.
F or example the small child more dependable on his parents specially the mother but as he grows up he became socially independence.
3. Intellectual development or Mental development
It is consider the key of essential communication with the child so need comprehensive study.
 4. Personality development
Individual personality development involves a summation of all physical, social and mental development and can be define as a sum total of all the expectation the person holds for himself.

 
Intelligence quotient: - I.Q
It can be use to quantify mental abilities in relationship to chronologic age
As define by Binet

Assessment of child development:
There is no specific measure can be used accurately to know child s developmental status. But certain questionnaire completed in the clinic which screening the major area of child development can give the dentist information about:
1. Behavioral adjustment.
2. Child mental age level.
3. Social majority level.
4. Physical status.
5. History of medical problem.

The pattern of behavior at certain age with expected development:
At 2 years at this age the child called in the preoperative stage and they vary greatly in their ability to communicate (terrible twos)
At 3 years. The child can communicate more easily than 2 years old. But they need their parents to remain with them in clinic to feel more security.
At 4 years old. The child usually listens and has a response with interest to dentist explanation and verbal direction.
At 5 years old. The child will have no fear of new experience if he properly prepare by the parents.
At 6 years of age. The child need proper introduction about dental treatment so he will respond in a satisfactory manner because the tensional manifestation rise to peak at this age .

The influence of the family on the child behavior
Family attitude and dental experience consider being the most important factors in determining a person reaction to dentistry because home environmental attitude.
Children are either accepting dental treatment gracefully or refuse it completely. This depend on how they have been prepared at home because emotions are contagious and child brought up in a home where the fear of dentistry is exaggerated show more concern and fear than child live in a family where dentistry discussed favorably .
Therefore for dentistry should never be employed by the parents as a threat or punishment, also explanation to the child need to be frankly.
Also parents should not be deceptive. If pain is involved, the child should be told to expect it. Beside that child first visit to dentist should be at an early age for a routine check up so he might get to know his dentist before an emergency develops.
Also a certain instruction should give to the parents
1. Tell the parent not to voice their own personal fears in front of their child.
2. Tell the parent never to use the dentistry as a threat of punishment.
3. Tell the parent to take their child to the dentist at early age to familiarize the child with dentistry.
4. Discuss with the parents about home environment and the important of moderate parental attitude in building a good dental patient.
5. Stress to the parents the value of regular dental care.
6. Tell the parent not to bribing their children to go to the dentist.
7. The parent should not promise the child what the dentist is or is not going to do.

Child behavior in dental clinic can be affected by types of parents which are very important:
1. Over protective parents
For example, parents who insist to remain with the child regardless of the situation or the age of the child that mean those parents often prevent the natural development of the child toward independence.
2. Manipulative parents
This behavior can be known by excessively demanding attitude like change in appointment time then extends to directing the course of diagnosis or treatment.
3. Hostile parents
This behavior include parents who question the necessity for treatment and this resulted from
1. Poor personal experience in the dental office.
2. General negativism toward health professionals.
3. Feeling of insecurity in a foreign environment,
4. Neglectful parents 
These behaviors characterized by the failure to maintain appointments, missing recall visits or not cooperate with respect with dental team.

Classifying children s cooperative behavior
Numerous systems have been developed for classifying the behavior of children in the dental environment.
Benefit of different types of classification
1-It can assist in directing the management method.
2- It can provide a means for systematically recording behaviors.
3- It can assist in evaluating the validity of current research.

A) the clinical classification (Wright)
This classification put the children behavior in three categories
 1. Cooperative child
Cooperative children are relaxed with little apprehension, and can be treated by straight forward behavior shaping approach mostly dental office experience affect child behavior in dental clinic.
2. Lacking in cooperative ability
This category includes 2 types of children.
1. Very young children who are uncooperative because of their age.
2. Children with specific handicapping conditions, these need special behavior management technique but changing in their behavior cannot be expected.
3. Potentially cooperative
This group also called behavior problem because clinically that child s behavior can be modified and become cooperative.
This behavior include the following:
1. Uncontrolled behavior
This behavior seen in young age between 3-6years. The reaction tan start in the reception room or even before entering the clinic also patient characterized by tears, loud crying and flying of the hands and le!\s.
2. Defiant behavior
This behavior can be seen in different age group but it more in  school age group. It can consider controlled but it known by shouting of the child I do not want or I want. Child behave in this way similarly at home and can called spoiled child , dentist can control child behavior by straight forward firm approach which change child behavior completely.

B) Frankl behavioral rating scale:
This scale divides the observed behavior into four categories, ranging from definitely negative to definitely positive. As follow.
1. Rating 1: Definitely negative refusal of treatment, crying forcefully, very fearful.
2. Rating 2: Negative reluctant  to  accept treatment,  uncooperative with some evidence of negative attitude.
3. Rating 3: positive + acceptance of treatment with cautions.
4.Rating4: definitely positive++ good rapport with the dentist, interested in the dental procedure.

Variables affecting child behavior in the dental clinic
A. Major variables
1. past medical history
The pain experience during past medical visit with its emotional quality is the most important in determining the behavior of children in the dental clinic. There is general agreement; those children who view medical experiences positively are more likely  to be cooperative with dentist. The emotional quality of past visits rather than the number of visits is significant .
previous surgical experiences  adversely influence behavior at the first dental visit, but this was not the case in subsequent visits.
2 .Maternal anxiety  (Parental anxiety)
Most investigations indicate a significant correlation between maternal anxiety and a child s cooperative behavior at the first dental visit. High anxiety on the part of parents tends to affect their children s behavior negatively. Although the scientific data reveal that children of all ages can be affected by their mothers anxieties, the effect is greatest with those under 4 years of age
3. Awareness of dental problem.
The tendency toward negative behavior at the first dental visit increases significantly when the child believes that he has dental problem. This occurs due to anxiety transmitted from mother to the child because mother recognized the problem first.
B. Minor variables
1. Socioeconomic status
Children from high social class consider to behave in a higher degree of cooperation in comparison with children from middle and lower class.

2. Rank of the child
The older child may become more anxious than children born later while middle child is usually more out going and suggestible because he use his older sibling and parent as a behavior pattern to follow.

3. Child s gender
The clear effect of the child s gender on behavior can be seen in the dental environment for example boys are expected to be braver stronger than girls  (Boys act as man and do not cry).

4. Child s age
There are differences in type of fear in different ages, like in 2 -4 years fear of imaginary creatures and small animals then 4 --6 years .start of social . and school fear. Then from 6years to adolescent fear related to injury, death and so on.

5. Attending to nursery school
Child attend nursery school cooperate more with dental procedure

6. Modeling: or imitation
Modeling can he the most effective means to introduce children into . . dentistry also modeling effective for patient s who have no previous dental experience.
 
Techniques of Behavior managements
There are 2 types of behavior management s techniques
1. Non pharmacotheraputic approaches•
Mean without using drugs
2. Pharmacotheraputic approaches
This by using drug in management of child but should be conscious when ,taking drugs and complete treatment.
STRATEGIE5 OF THE DENTALTEAM
A primary objective during dental procedures is to lead children step by step so that they develop a positive attitude toward dentistry. Fortunately, most children progress easily and pleasantly through their dental visits without undue pressure. on themselves or the dental team. These successes can be attributed to a number of factors; such as a child s confident personality, a parent s proper preparation of the child for the appointment or a dental team s excellent communicative skills. On the other hand, some children s dental office experiences cause anxiety and the beginning of a negative dental attitude. Sometimes these controllable but apprehensive children are managed without medication, provided that appropriate non pharmacologic psychological techniques are employed. .
preappointment behavior modification.
Psychologists have developed many techniques for modifying patients behaviors by using the principles of learning theory. These techniques are called. behavior modification.
Preappointment behavior modification define as anything that is said or done to positively influence the child s behavior before the child enters a dental operatory. The merit of this strategy is that it prepares the pediatric patient and eases the introduction to dentistry. It has received great deal of attention because the first dental visit is crucial in the formation of the child s attitude toward dentistry.
Several methods of preappointment behavior modification are recognized.
1. Films or videotapes have been developed to provide a model for the young patient. The goal is to have the patient reproduce behavior exhibited by the model. On the day of the appointment, or perhaps at a previous visit, the new pediatric patient views the presentation.
2. Live patient modes: such as siblings, other children, or parents. Many dentists allow young children into the operatory• with parents to preview the dental experience. Because the observing child likely will be initiated into dental care with a dental examination, a parent s recall visit offers an excellent mode ling opportunity. On these occasions many young children climb into the dental chair after their parents appointments.
3. Preappointment mailings: precontact with the parent can provide directions for preparing the child for an initial dental visit and therefore can  increase the likelihood of a successful first appointment. Precontact offers a practical approach for teaching parents of new pediatric dental patients how to prepare their children for a first dental visit.

 
FUNDAMENTALS OF BIEHAVIOR MANAGEMENT
Positive Approach: There is general agreement that the attitude or "expectations of the dentist can affect the outcome of a dental appointment; The child will respond with the type of behavior expected. Thus positive statements increase the chances of success with child. "
To obtain success with children, it is, important to anticipate success.
Team Attitude: Personality factors such as warmth and interest that can be, conveyed without a spoken word are critical when dealing with children. A pleasant smile tells a child that an adult cares; Children respond best to a natural and friendly attitude. Children also can be made to feel comfortable In the dental office by the use of nicknames, which can be placed on  "patient s record.
organization: Plans in the dental office have many dimensions. each dental office must devise its own contingency plans. and the entire office staff must " know in advance what is expected of them and what is to be done Such plans are key features of many pediatric dental offices because they increase efficiency and contribute to successful appointment.
 Truthfulness: Unlike adults, most children see things as either "black" or "white." The shades between are difficult for them. to discern. To youngsters the dental health-team. is either truthful or not. Because truthfulness is extremely important in building trust, it is a fundamental rule for dealing with children.
Tolerance: A seldom-discussed concept, tolerance level varies from person. to person. It refers to the dentist s ability to rationally cope with misbehaviors while maintaining composure. Recognizing individual tolerance levels is especially important when dealing with children. As well as varying from person to person, tolerance levels fluctuate for a given individual. For example, an upsetting experience at home can affect the clinician s mood in the dental office. Some people are in a better frame of mind early in the morning, whereas the coping abilities of others improve as the day progresses.
Flexibility: Because children are children, lacking in maturity, the dental team  must be prepared to change its plans at times. A child may begin fretting or squirming in the dental chair after half an hour, and the proposed treatment may have to be shortened. On the other hand, a dentist may plan an indirect temporary pulp treatment, but because the child is difficult, the plan may have to be altered to complete treatment at a single session .

COMMUNICATING WITH CHILDREN
Several effective communication techniques can be suggested. These key points are guidelines not inflexible rules, one must always be prepared to improvise as the situation requires. .
Establishment of Communication:
The first objective in the successful management of the young child is to establish communication. this generally agreed that involving a child in a conversation not only enables the dentist to learn about the patient but also" may relax the youngster. There are many ways of initiating verbal communication, and the effectiveness of these approaches differs with the age of the child.
 Generally, Verbal communication with younger children is best initiated with complimentary comments, followed by questions that elicit an answer other than yes or no.
Establishment of the Communicator:
Members of the dental team must be aware of their roles when communicating with a pediatric patient. Generally the dental assistant talks with the child during  the transfer from reception room to operatory and during preparation of the child in the dental chair.
When the dentist arrives, the dental assistant usually takes a more passive role, since the child can listen to only one person at a time. It is important that communication occur from a single source. When both dentist and dental assistant provide directions ,the result maybe a response that is undesirable simply because the child becomes confused.

Message Clarity:
Communication is a complex, multisensory process. It includes a transmitter, a medium, and a receiver. The dentist or dental health team is the transmitter, the spoken word frequently is the medium, and the pediatric patient is the receiver. The message must be understood in the same way by both the sender and the receiver.

Problem Ownership:
In difficult situations, dentists sometimes forget that they are dealing with children.
They begin by sending "you" messages. For example, "You must sit still!" These are negative messages and only undermine the rapport between a pediatric patient and dentist. "You" messages carry the implication that the child is wrong. An alternative is to send "I" messages. These messages establish the focus of the problem, such as "I can t fix your teeth if you don t open your mouth wide"
Active Listening:
Listening also is important in the treatment of children. However, listening to the spoken words may be more important in dealing with the older child than it is in dealing with the younger child, for whom attention to nonverbal behavior often is more crucial.
Appropriate Responses:
"the response should be appropriate to the situation_" The appropriateness of the response depends primarily on the extent and nature of the relationship with the child, the age of the child, and evaluation of the motivation of the child s behavior. All inappropriate response would be a dentist s displaying extreme displeasure with an anxious young child on the first visit when there has been insufficient time to establish a good rapport. On the other hand, if a dentist has made inroads with a child, who then displays unacceptable behavior; a dentist may well express disapproval without losing personal control. The response is then appropriate.

BEHAVIOR SHAPING 
Behavior shaping is a common non pharmacologic technique. It is a form of behavior modification. It is based on the established principles of social "learning. By definition, it is that procedure which very slowly develops with the child patient in order to provide a treatment. It is a simple method of teaching the child step by step what is expected of him in dental clinic. This technique reinforces the desired behavior of the child gradually.
The dentist should establish strong positive contact. This method can be used with children who show a good cooperation to start communication with them while children with negative behavior, firstly need to change their behavior to cooperative then using this technique.
The procedure used called TSD method which means Tell show Do method The dentist explain to the child what he is going to do in a language that the child can understand in a slow and repeated word until the child aware of what will happen in dental seat.
This method indicated for young child and for first time also can use for fearful child because of bad dental experience in another clinic.