behavior management ppt [compatibility mode]bw

8/10/2019 Behavior Management PPT [Compatibility Mode]BW

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Natalie O. Ford, DMD

Children are NOT Little Adults!


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Att itude of

dentists

Att itude of

dentists

Violence in society

Multicultural

Divorce (26% in 2

parent households)

Mental health

rather than

discipline

Unacceptable

behavior

management

techniques

Worse

Negative

parenting

Limit setting

Dentists less

assertive in

management style

The ChangingLandscape

Parental

Factors

Parental

Factors

SocietySociety

Not alwaysobjective

Mothers tend tounderrate all

negativebehaviors

Mothers seemsurpr ised at

childs poor oralhealth

{sometimes}

Mothers see morenegative

behaviors in otherchildren

A Mothers Observations


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4 Stages

Sensory Motor

0 to 2 years

Preoperational

2 to 7 years

Period of ConcreteOperations

7 to 11 years

Period of FormalOperations

11 to adult

Sensorimotor Period (0-2)

Child Infant

Objects in environment = permanent

Difficult communication (language

capabilities)

Little ability to interpret sensory data

Can think of time only in

the present


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Preoperational Period (2-7)

Use words to symbolize objects

Egocentric

Limited logical reasoning (dominated

by immediate sensory impression)

Animism inaminate objects

have life

Period of Concrete Operations

(7-11)

Improved reasoning

Can see other points of view

Ability to reason tied to concrete

objects

Limited abstract thinking


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Period of Formal Operations

(11-adult)

Intellectually treat like an adult

Have abstract reasoning & concepts

Do NOT talk down to a child

Lets Review

Each Age!


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Ages

2 Ages

CHRONOLOGICAL AGE

MENTAL AGE

ADDRESS the childs MENTAL

AGE

2 Year Olds terrible twos

Varied vocabulary

Solitary play, SHY

AFRAID of NOISE, sudden

movements

React better to showing rather

than telling Does not want to be separated

from parent


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2.5 Year Olds

Suggestible

Usually instinctive

May generalize (may see

white coat, and feel like at

the pediatrician)

Not interested ininterpersonal relationships

3-3.5 Year Olds

Better communication

Will develop interpersonal

relationships

Imaginative

Follows directions

Uncertain/insecure Will often sepearate from

parent


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5.5-6 yo

School age

Moves away from close family

dependency

Anxiety (new situations)

changed child

Prone to temper tantrums

May be afraid of animals, people,

darkness, bodily harm

6 yo

Anxieties diminish, behavior improves

Well adjusted, happy

Usually reacts favorably


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7 yo

Better control Somewhat withdrawn, moody, sulky

Anxious to please, CONSIDERATE

GIVE PRAISE

More verbal

Deep, worrisome fears (about acceptance)

Dont like to be touched

Fantasy, super-imaginative

8 yo

Dramatic, tall tales

Critical of themselves/others, sensitive

Verbal aggression

Fewer fears

More adaptable

Interested in relationships

Desires to be treated as an adult

NEVER DEMEAN


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9 yo

More responsible, independent,cooperative

Likes compliments, competitino

Self-critical, uncertain

Extreme emotional states

Fewer fears

Upset by own mistakes

Expected to be on own more

10 yo

Wonderful

Easy going, well-balanced

Infrequent anger (violent, but quickly

resolved)

Wants adult relationships

Matter of fact


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11 yo

BEHAVIOR PROBLEM- mostworried/fearful age

Health worries

FEARS: unknown, animals, INJECTIONS

Genuinely afraid of dental procedure

Sensitive

Proud, selfish, competitive,

belligerent, jealous, resentful Detailed conversation

12 yo

Well adjusted, happy

Want to be treated as an adult

Likes HUMOR

Preoccupied w/ food & eating

Usually not a problem in the dental office


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13 yo sad

14 yo outward, well adjusted

15 yo dislike authority, may blame

dentist

16 yo happy, well adjusted

BEHAVIOR MANAGEMENT

A continuum of interaction

Purposes:

Establish rapport

Promote + behavior

Facilitate effective, efficient, safe treatment

Base decisions off risk vs benefit


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ev ew o e av or

Management Terms

behavior: observable act that can be describedor measured reliably

Classical conditioning: conditioned reflexes

established by association of one stimulus w/

another stimulus thats known to cause

unconditioned reflex

Behavior modification: shaping

behavior

Behavior Modification

Stimulus-response

Motivation

+ reinforcement: right response produces a

goal/reward response reinforced

- reinforcement: response takes away an

unpleasant stituation

Generalization: may react to newsituation as if an old, similar situation

Discrimination: opposite of

generalization


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Behavior Mod . . . Cont.

Extinction: response not reinforced, thenresponse decreases until eliminated

Adverse conditioning: punishment

Desensitization: present milder component of

stimulus until no longer produces anxiety

Modeling: imitation

Successive approximations: reinforce behaviors

that more & moreclosely resemble the final desired

response

GOALS

Quality treatment

Trust, reduce fear

Positive attitude

Reinforce positive behavior

Extinguish inappropriate behavior


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Behavioral Evaluation

Parentalinterview(Parent-Dentist)

Developmentalmilestones

Social and healthhistory

At ti tudes and

Expectations

Indirectobservation ofChild-Parent

interaction byDentist

At tachmentand

temperament

Direct childinteraction

(Child-Dentist)

Behavior Eval

Child Temperament/Attachment

TEMPERAMENT

Childs interaction with the environment

Childs initial response to new situations

Easy, difficult, slow to warm up, mix

ATTACHMENT

Childs intensity of interaction withcaregiver

High intensity indicates emotional

immaturity and insecurity


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TEMPERAMENT

Easy:

Highly regular in biologic functions

Positive approach to new stimuli

Rapidly adaptable

Frequent positive moods

Low or mildly intense reactions

Difficult:

Irregularity of biologic functions

Withdrawal response with newstimuli

Very slow in adapting

High frequency of negative moods

Frequent intense negative reaction

Attachment: emotional bond felt byhumans to special people in their lives

Occurs in latterpart of first yearof life

Central part ofcognitive andsocialdevelopment

Once securebase formed ,

child isconfident in

exploring the

environment

Lack ofattachmentmay confersome risks ofbehaviordifficulties l ater

in life


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FEAR

Greatest management problem = primary emotion, feeling of impending danger,

cognitive development link

Types of Fear

Objective Fears responses to stimuli that are

felt, seen, heard, smelled, or tasted that are of a

disagreeable or unpleasant nature

Subjective Fears based on feelings or

attitudes that have been SUGGESTED

Imitative fears subtle transmission, parent

displays and child acquired withoutbeing aware of it


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Common Fears

Age 1-2

Largemovements

Loud sounds

StrangersSeparation

Age 3-4

AnimalsBeing alone

Imaginarycreatures

Physical harm

Dark

Age 5

Decrease infears

Age 6-8

School failure

Ridicule

Death of lovedone

DENTAL FEAR

History of non-invasive = less fear

Coping skills increase with history of non-

invasive appointments

Childs perception of appointment is decisive in

developing fear- over preparation

Dentist empathy childs perception of dentist

Parental fear Childs temperament

Age & gender


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Anxiety

= apprehension,tension, or uneasiness whichstems from the ANTICIPATION of danger, the

source of which is largely unknown or

unrecognized, intra-psychic

Often indistinguishable from fear

BEHAVIOR TYPES

Cooperative

Lacking cooperative ability

Potentially cooperative = pre-cooperative

Uncontrolled behavior

Defiant behavior

Tense-cooperative behavior

Whining behavior The fearful child

The timid/shy/bashful child


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Types of Crying

ObstinateCrying

ObstinateCrying

FrightenedCrying

FrightenedCrying

Hurt CryingHurt CryingCompensatory

CryingCompensatory

Crying

Reasons for Adverse Behavior

Fear

Lacks

comprehension

- Dental

procedures,

personnel, office

env

Immature or

impaired

development

Impairments

- Stability & m

control

- Impulse

control

Safety =

paramount

- For patient &

dental team


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Behavior Management

Begins at 1st Contact

InitialContact &

AppoinmentScheduling

InitialContact &

AppoinmentScheduling

Pre-VisitLetter ifDesired

Pre-VisitLetter ifDesired

DentalEnvironment

- Officedesign &decor

DentalEnvironment

- Officedesign &decor

TreatmentAround

OtherChildren

TreatmentAround

OtherChildren

Pre-Visit Letter

Includes:

Appointment confirmation/time

Express appreciation

Details of first visit

Specific information fees, policies

Advantages:

Education Parent understands how to prepare

child

Parent understands visit is

DIAGNOSTIC


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Dental Environment

Childrens corner in reception area toys, puppets, books, games

Childrens corner in reception area toys, puppets, books, games

Operatory adult chair OK to treatchildren, sound control?

Operatory adult chair OK to treatchildren, sound control?

Consultationrooms

Consultationrooms

Bright, attractivecolorful walls,

pictures

Bright, attractivecolorful walls,

pictures

Preventiveorientation sink

& mirror atchilds height

Preventiveorientation sink

& mirror atchilds height

INFORMED CONSENT

Legal standard requires that theconsenter be:

informed

competent

acting voluntarily

Doctorpatient relationship is: fiduciary

not dominate/subordinate


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Prognosis ofProcedure

- good- fair-poor

Prognosis ofProcedure

- good- fair-poor

Possible need forunforeseen treatment,

or change of treatmentas planned

Possible need forunforeseen treatment,

or change of treatmentas planned

Prognosis if procedurenot undertaken

Prognosis if procedurenot undertaken

Alternatives to

proposed procedure- sedation (may stillrequire immobilization)- treatment under GA

Alternatives to

proposed procedure- sedation (may stillrequire immobilization)- treatment under GA

INFORMEDCONSENTELEMENTS

INFORMEDCONSENTELEMENTS

Distraction

Voice

Control

Nitrous

Oxide

Positive

Reinforce

TSD

ParentalPresence

Absence

Non-verbal

Basic BehaviorGuidance


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Non-invasive ManagementTechniques

Communication-based techniques

Do not require separate informedconsent

Designed for helping child cope with anxiety

contingency management

behavior shaping

TELL-SHOW-DO

Tell: Explain what going to do (before, during,

while)

Truthful

Use words child understands, dont talk down to

Be cautious with fear-promoting words

Bother instead of hurt

pinch instead of stick

Show: show what to expect

Anesthesia: pinch hand as demo

Avoid fear promoting instruments

Do: do it, use same voice


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This is how I count my fingers.

Lets count your

fingers!

Lets count some teeth!.

DENTAL TERM WORD SUBSTITUTE

Air Mr. Wind

Water Water-gun

High speed handpiece Mr. Whistle sings to you

Low speed handpiece Mr. Bumpy

Anesthetic Sleepy juice

Burr Brush/pencil

Caries Sugar bugs, brown spot, sick tooth

Explorer Tooth counter

Evacuator Vacuum cleaner, straw

Impression material Pudding, mashed potatoes

Matrix Filling fence, ring

Prophy paste Special toothpaste

Fluoride Vitamins

Rubber dam Raincoat

Rubber dam clamp Tooth button/ring

Rubber dam frame Coat rack

Dental

term

substitute

SSC Tooth hat

SS band Tooth ring

X-ray head Camera

X-ray picture


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Distraction

Verbal distractions

Walkman-typeheadphones, handheldgames

Ceiling-mounted posters

TV

Distracters

Distracters must be

intense to competewith patients desire toescape

Alterat ion o f

body, tone, or voice

Appropr iate child

adult roles

Gain attention,

compliance

VOICE CONTROL

HEY . . . STOP THAT.

THATS NOT ALLOWED

HERE

Sudden, firm

commands.

Facial

expression

must mirror

tone.


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Voice Control

Rated as unacceptable by

parents (takes authorit yfrom parent)

Perceived as aggressive

Alternate method lowertone, cooperation as

choice, and disruptivebehavior wil l require a

start over

Praise desired behavior

Make sure negativebehavior is not r elated to

actual pain

Parental PresenceWide diversity in practitioner philosophy andparental attitudes regarding presence orabsence

Parenting styles coping skills and self-discipli ne required to deal with newexperiences

Communication can be hampered

Range great benefit / disaster

Always with Spec ial Needs Chi ld

Parent must be part of solution and not part ofproblem


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INFORMED

CONSENT aMUST before the

Following

Behavior

ManagementTechniques!

Stabilization Protective stabilization = immobilization = restraint

= support

Good for patient and personnel safety when

absolutely necessary

Use least restrictive necessary

ACTIVE STABILIZATION

Caregiver/assistant/dentist performs

Ex: holding arms, legs, head

PASSIVE STABILIZATION

Ex. Pediwrap, papoose board


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Passive Stabilization

Active Stabilization

Hand Over Mouth / Flooding Used to re-establish communication when a

child has become hysterical/defiant

** child must be of normal intelligence

HAND OVER MOUTH tell child must stop

screaming in order to remove hand

NEVER use with frightened children, NEVER

do if angry

DONT DO


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Nitrous Oxide Sedation

* Low

solubility in

blood

* Excreted

unchanged

in the lungs,

and readily

diffuses into

alveolar

membranes

Side effects:

diffusion hypoxia

nausea

Correct total

liter flow is

determined

by the

amount

necessary to

keep

reservoir bag

1/3 to 2/3 full.

Contraindications:URI

Psychotic hx

Conscious Sedation

Premedication oral, nasal,

parenteralroutes

Premedication oral, nasal,

parenteralroutes

Special permitsrequired,

certification,training. Need

experience

Special permitsrequired,

certification,training. Need

experience

Must have

specialequipment,monitor for

emergencies

*PULSE OX

Must have

specialequipment,monitor for

emergencies

*PULSE OX

Know:

- Age

- Weight (use weightthat is the least b/tdosing and ideal

weight)

- Mental attitude

- Drugproperties/dosing

Know:

- Age

- Weight (use weightthat is the least b/tdosing and ideal

weight)

- Mental attitude

- Drugproperties/dosing


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General Anesthesia

General Anesthesia- IndicationsWeigh Risks vs. Benefits

mental

disabilities to

degree that dentist

cannot

communicate.

adequate

cooperation

cant be achieved

by usual behavior

management

techniques,

predmedications,

or acceptable

physical

restraint

Multiple

quadrants that

will require multiple

appointments

in the young

child

Systemic

disturbances

and congenital

anomalies that

dictate general

anesthesia


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Deferred Treatment

ART

Risk/benefitPreventiveprogram

Review of Dos

and Donts


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Dos Be prepared (children have small attention span), start on

time Be relaxed

Introduce yourself & get to know child

Give child lots of attention

Explain everything

Compare to children in + ways

PRAISE (not flatter)

Allow to use restroom before and drink of water if ask

Make everything pleasant

Avoid getting mad

Keep communicating Set limits

Establish signals (to convey feelings/concerns)

Enjoy yourself

Donts Lie

Make fun of the child

Scold/ridicule

Compare to other children in a negative way

Be too loud/forceful/overbearing

Use baby talk or talk down

Dont ignore

Use words that incite fear (needle, cut, drill, sharp, stick,

blood, sting, shot, bur, bite, pull, break)

Carry without parents permission

Be over-sympathetic Ask questions where child can say no

Allow child to see scary instruments


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Some Key Law Terms to

Know and AVOIDAssault = An intentional display of force that would give

the victim reason to fear or expect bodily harm; which

may be committed without touching or bodily harm

Battery = Unlawful application

of force to the body of another;unprivileged touching of

another persons body

MEDICAL BATTERY

- no need to prove injury or negligence- Necessary to prove that the medical personnel engaged in

unauthorized touching, contact or handling of the victim

- Ex. Perform treatment without informed consent

MEDICAL MALPRACTICE

- negligent acts performed by medical personnel


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QUESTIONS??

Works Cited:

Rockman, Roy A. Child Taming: How to Manage Children in Dental Practice

Furnish, Guy. University of Louisville School of Dentistry Pediatric Manual

behavior management ppt [compatibility mode]bw

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