Pedo Sheet #3 By Hanan Musleh

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Pedo Sheet #3 By Hanan Musleh

Post by Sura on 1/3/2012, 6:33 pm


عدد المساهمات : 484
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تاريخ التسجيل : 2010-09-29

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Re: Pedo Sheet #3 By Hanan Musleh

Post by Shadi Jarrar on 2/3/2012, 1:05 am

Pediatric Dentistry
Behavior Management in Children
Dr. Suha Abu Ghazaleh
Lecture #3
This is a non-pharmacological behavior management technique.
Behavior management: is the means by which the dental health team can effectively and efficiently perform treatment for a child.
The aim is to instill a positive dental attitude.
Remember: Every child is different and every practitioner is different, the way you deal with each child will vary, and every one of us will treat our young patients differently according to our personalities.
There are a number of non-pharmacological techniques that aim to help manage patient behavior, these techniques are described individually, however usually when you're in the clinic you don’t make a conscious decision to employ one certain technique, they usually intermingle with one another (used in combination). But we need to understand them individually.
We have 10 techniques that we'll take.
1.) Preparatory Information
2.) Non-verbal communication
3.) Voice Control
4.) Tell-show-do
5.) Enhancing Control
6.) Behavior Shaping and Positive Reinforcement
7.) Modeling
8.) Distraction
9.) Systemic desensitization
10.) Negative reinforcement

1.) Preparatory Information:

It is the information that the child and his family gets before they actually come to see you, usually in the form of a letter, or by discussing the office procedure on the initial telephone call.

In the US and England, once the patient makes an appointment with the dentist, the dental office sends the patient a letter in the mail to confirm the appointment, and to let the patient and his family know what may take place during their visit. We can employ this technique over the phone, by having our receptionist instructed to inform the parents what to expect in their first visit when they call to make an appointment.

Such letters will inform the family about what will happen at the visit, give advice about preparing the child, and also reduce parental anxiety.
In the previous lecture we took about the importance of parental anxiety, especially maternal anxiety (as the mother has more contact with the children in most cases). We have to make it clear to the parents not to frighten their children, for example in many cases the parents tell their children to sit and behave or else the dentist will give them a needle injection. In these instances the parents have prepared their child to be afraid of the dentist and of their visit. We have to try to make the visit as pleasant as possible.

Preparing the parents is an essential part of preparing the children.
Studies found that children with families that received a letter were more cooperative, and the mothers found it to be helpful to be given a list of instructions on what to tell their kids. So even the parents need to be prepared on what to tell their children.

These days with the use of the internet and customized web-pages, these serve as educational tools that help the parents and the child be better prepared for the first visit and they answer questions that help to alleviate any concerns.

2.) Non-verbal Communication (body language):

It is a means of communicating without the use of words and speech, by reading somebody's body language you can interpret what that persons intends to say.

About 70% of communication is non-verbal, and only 30% is verbal. Non-verbal communication is more important than verbal communication (especially regarding children), you can tell whether someone is telling the truth or not by observing their body language.

Non-verbal communication is the reinforcement and guidance of behavior through appropriate contact, posture, facial expression, and body language.


 To enhance the effectiveness of other communicative management techniques.

 To gain or maintain the patients attention and compliance.

So basically our words and speech are enhanced by our non-verbal communication, and again it helps us gain the patients attention. For example, by placing your hand on the child's shoulder while speaking to him/her, and by going down to their level; this is especially important for tall male dentists because children find them more intimidating.

Another way of employing non-verbal communication, is by preparing your clinic for children, by having the dental team as relaxed as possible, having the clinic child-friendly.

Non-verbal communication occurs continuously and may reinforce or contradict verbal signals, an example of non-verbal communication is having a child-friendly environment and a happy smiling team. It all helps in getting the children relaxed and in gaining positive behavior in the dental chair.
Gentle pats or squeezes on the shoulder minimize stress, sitting and speaking at eye level allows for friendlier and less authoritative communication.

What are the three essential messages that you're trying to convey to children through non-verbal communication??

1.) I see you as an individual and will respond to your needs as such.
We need to make it clear to the child that there is empathy between us, that we feel with them as an individual.
2.) I am thoroughly knowledgeable and highly skilled.
We need to be self-assured while working so that they feel confident in our ability.
3.) I am able to help you and will do nothing to hurt you needlessly.

3.) Voice control:
This technique uses a controlled alteration of voice volume, tone, or pace (by speaking more rapidly or slowly) to influence and direct the patients behavior.
Young children often respond to the tone of voice rather than the actual words. When children are under stress they're not really listening to what you're saying, what mainly draws their attention is your tone of voice.
For example when you want to administer a L.A. injection to a child, you've already prepared him/her, you've applied topical anesthetic and employed all the correct behavior management techniques, yet in spite of all this the injection will still hurt the child, or at the very least it'll cause them discomfort. During this time you should speak to the child and try to distract him/her; " how's school going with you? Do you like your teacher?…etc" so when they feel pain and reflexively raise their arm, you tell them to lower it in a different tone of voice: "LOWER YOUR ARM/ NAZEL 2EEDAK" once they lower it you go back to using your regular tone of voice. This is NOT considered shouting at the child, what we're aiming to do is to direct their attention to a specific task by changing our tone of voice.
It is used with children, but not very young children because they might get frightened and then lose control if we used voice control with them.
Again, it is NOT acceptable to shout and yell at the child, but you may change your tone of voice in order to gain their attention for a certain procedure.
It aims to improve attention and compliance as well as to establish authority. Sudden and firm commands are used to get the child's attention or to make the child stop what he/she is doing. It may not be acceptable to all parents or clinicians (as we said there are differences among clinicians and among parents and their children). It is not appropriate for children too young to understand or for the mentally handicapped, by raising your voice they'll interpret it as yelling and they won't understand what's going on, so it'll just serve to frighten them.
Voice control is used only in certain instances, and then we go back to using our usual tone of voice.
This is the technique that we will use the most in our clinics, you tell the child what you're going to do, you show them, and then you actually do it. It is very commonly used. When children first come to the clinic they don’t know what to expect, everything is new to them from the dental chair to the instruments, so you need to show them everything, you need to tell them about it before you commence the actual process.
The TELL phase involves verbal explanation of the procedures in phrases appropriate to the developmental level of the patient and to their level of understanding. If you have a 5 year old patient you explain the procedure to him/her differently than you would to a 10 year old one.
The SHOW phase is used to demonstrate the visual, auditory, olfactory, and tactile aspects of the procedure in a carefully defined non-threatening setting. For example you want to tell them about the low-speed hand piece, you say: "we use this to get rid of all your caries"; "hay imnesta3melha 7atta innadef feeha ilsooseh, binrosh 3aleeha may 7atta tendaf". Then you tell them to listen to the sound it makes, "it's like a motorcycle and it sprays water too!". We try to make it as kid-friendly as possible. We need to explain to them what they'll feel when we start, so you can say: "it'll feel like I'm tickling the cavity/ bit7as zay ka2anne ba "garger" ilsooseh" …..(all these are the doctors words  I apologize for having to use this language but these are sentences we'll need to know to use in our clinics, it's not like we're going to tell the kid "okay I'm just going to clean your caries now").
Just try to make the child understand and know what to expect once we start the procedure in a way that is appropriate to their level, and by integrating our own personalities, this will make it easier for us to do the job and it'll help relieve the child's anxiety.
The DO phase is initiated with minimum delay, and without deviating from the explanation and demonstration. We took the time to talk to the child, explain everything, and show him/her, after that you start doing the procedure immediately without any delay. All our instruments should be ready and on-hand so that no setback occurs.
**We do NOT apply the tell-show-do technique for giving a needle injection, we don’t show the child the needle beforehand because it'll only serve to scare them, but we do tell them what they may feel. "We're going to put your tooth to sleep/ bidna innayem ilsin, bidna inrush 3aleeh dawa binaymoh, ra7 it7es sha3'leh bardeh binrosh-ha janbo" . So we don’t tell the child that they won't feel a thing, because he/she will feel something so they should know to expect this. Again, you never show them the needle. In order to ensure the child doesn’t see the needle, we can ask him to close his eyes, or we can cover his/her eyes with a mask, or by assembling it behind the child.

1.) To teach the patient important aspects of the dental visit, and familiarize the patient with the dental setting.
As we said everything is new and unknown to them , so you should take the time to familiarize them with their surroundings.
2.) To shape the patients response to procedures through desensitization and well-described expectations.
We'll talk about desensitization and it's extremes later on, in general desensitization is to continuously expose the child to the instruments and their surroundings in the clinic.
Tell-Show-Do is widely used in children's dentistry to familiarize a patient with a new procedure. The technique is well accepted by parents, they really like this technique, they feel that you are taking the time to explain to their children what to expect, and they really appreciate what you're doing.
Avoid sudden movement; for example when you start to adjust the positioning of the dental chair this may startle the child so tell them beforehand what you're going to do.
Do not ask permission, after you took the time to explain all about the low-speed hand piece, and you're ready to start don’t ask the child to open their mouth: "mmkn tefta7 tomak?" they may just say no and that’s that. So don’t ask for their permission, tell them, show them, and then just say "yella ifta7 tomak bidna in7otha jowa w innadef ilsin" and start.
Use word substitutes:
Actual word Word substitute
Slow-speed hand piece buzzy bee/ motorcycle
High-speed hand piece Mr. Whistle/ fast car
Local anesthetic sleepy juice
Giving a local anesthetic spray your teeth off to sleep
Rubber dam rubber raincoat
Rubber dam clamp clip/button
Fissure sealant tooth paint
Suction vacuum cleaner
Amalgam silver star
Air/water syringe wind gun/ water gun

So we should try to find substitutes for the names of our instruments that kids will find cool and interesting, for example when you want to use the spoon excavator: "hay ilma3la2a ille binnadef feeha", probe: "hada bin3id feeh ilasnan". Show the child the mirror and let him/her take a good look at it.
5.) Enhancing Control
Here the patient is given a degree of control over their dentists behavior through the use of a stop signal, usually raising an arm. so that they don’t feel that they have no power whatsoever over what's being done to them, by giving them a way to stop the procedure.
Such signals have been shown to reduce pain during routine dental treatment and during injections. The stop signal should be rehearsed and the dentist should respond quickly when it is used otherwise it is ineffective.
Enhancing Control is like a stop sign, we should make it clear to the child that they are the ones in charge, we tell them that if they need anything, want to stop or want to tell me something all they have to do is just raise their right hand, whenever they raise their hand you have to stop what you're doing and see what they need.
After you tell this to the child, the second you start the procedure most likely the child will immediately raise his hand, you need to stop, and ask him what he needs.
With this technique the child feels that there is a way for them to control the situation, and it is a very effective technique.
Sometimes it may become tiresome, the child might raise his hand for everything you do, in such instances you can move on to "counting" . Counting is very effective combined with enhancing control, you tell the child we'll count to 3 and then we'll stop: "1….2…..2.5…..3" and then you stop, this is another way of giving them control but at the same time getting things done.
6.) Behavior Shaping and Positive Reinforcement:
Positive reinforcement: is giving the patient a positive response to anything good that they do so as to shape their behavior towards cooperating while in the dental chair.
Behavior shaping: that procedure which very slowly develops behavior by reinforcing successive approximations to a desired goal.
Our goal is that the child sits comfortably in the dental chair in a relaxed manner, is cooperative; opens his/her mouth and accepts the dental treatment. This won't happen all at once, there are steps we aim to reach, and every step the child takes towards our desired goal we give him/her positive reinforcement in order to motivate him/her towards taking the next step.
Many dental procedures require quiet complex behaviors and actions from our patients which need to be explained and learned. Dental work is not pleasant at all for the patient, as adults we have coping skills, we can force ourselves to endure, whereas children differ in their level of coping skills. They need to be taught to cope with it, and to be taught what to expect gradually, you shouldn’t push them too far.
For children this requires small clear steps, this is most easily achieved by selective reinforcement. Every time they do something right we should give them positive feedback about it.
Reinforcement (positive feedback): is the strengthening of the pattern of behavior, increasing the probability of that behavior being displayed again in the future.
So if there is a pattern of behavior that we like, something the children are doing right we should give them positive feedback in order to strengthen this action and so that the child will want to repeat this behavior again. This works great with children because they are conditioned to want to please adults.
Anything that the child finds pleasant can act as positive reinforcement; such as giving them stickers, crayons, or badges, these are often used at the end of a dental appointment. However, we should avoid giving them candy and chocolate at the end of the appointment because we're not sending them the right message. Giving the child presents is fine, but what's most important is social stimuli (giving him positive reinforcement during the actual visit and talking to him), this is a lot more effective than staying silent during the entire appointment and then at the end "oh here's a present".
The most powerful reinforcers are social stimuli such as facial expressions, positive voice modulations, verbal praise, and appraisal by hugging.
Reinforcers work best when applied directly after the appropriate behavior, for example when the child opens his/her mouth when they're told, you immediately respond with verbal praise "great job/ bravo", and they should be selective to the exact action they just did so that the child knows what he/she is being praised for and hence will try to repeat it.
Be as specific as possible, since specific reinforcement is more effective than a generalized approach. In the dental clinic this means continuous praise from beginning to end not just a "well done" as they leave you.
7.) Modeling
Positive modeling: the technique is based on the principle that people learn about their environment by observing others behavior.
Children act as models for each other, this can be either positive or negative, for example in our clinics atleast one of us is bound to have an uncooperative patient who may scream, cry, yell and refuse treatment, this acts as a negative model for the other children.
A model is used either live or by video to exhibit appropriate behavior in the dental environment. For best effects models should be in the same age group as the target child, should exhibit appropriate behavior, and be praised. They should also be seen entering and leaving the clinic.
Later on, in our own clinics we can get the most out of this technique by scheduling appointments for children that are in the same age group in close proximity to each other, for example pre-school kids could be scheduled for the mornings, and school kids for the afternoon.
8.) Distraction
Trying to distract the child from something unpleasant that is being done.
This approach aims to shift the patients attention from the dental setting to some other situation, or from a potentially unpleasant procedure to some other action. Recent clinics nowadays are equipped with a TV screen in front of the patient, where we can put cartoons on for the child to watch to distract their attention from the dental setting.
The Distraction technique can be applied to certain procedures, like when giving a local anesthetic injection you need to distract the child, for example by pulling their lip so that the child won't know what to concentrate on; the needle or their lip. Also, distraction with words (distracting the child by talking to him/her) while giving the injection is helpful: "How do you like school?, What grade are you in?".
 To decrease the perception of unpleasantness.
Since it’s a perception, its mostly felt when you concentrate on it; so when the child is distracted this feeling will be reduced.
 To avert negative or avoidance behavior.
Cartoons have been shown to reduce disruptive behavior in children when combined with reinforcement. Cartoons are good distractions but they are most effective when the child is warned that they'll be turned off if they don’t behave; this is a form of negative reinforcement. Later studies suggest that audio tapes may be more effective.
9.) Systemic Desensitization
In general terms systemic desensitization is continuously exposing the child to the dental setting time and again.
We probably won't use this technique much in the clinic; it's very specific but we need to know about it. It involves phobic patients, patients with phobia from the dental setting.
The technique helps individuals with specific fears or phobias overcome them by repeated contacts. We introduce the child to a hierarchy of fear-producing stimuli in an ordered manner starting with the stimulus posing the lowest threat, so this is done with patients that know what it is exactly they're afraid of. This should be done in a gradual manner.
Phobia is a persistent, abnormal, and irrational fear of a specific thing or situation that compels one to avoid it despite the awareness and reassurance that it is not dangerous. It is a form of exaggerated fear.
A true dental phobic would not be able to even consider the prospect of attending a dental practice.
This technique has two elements: firstly gradual exposure to the fear-inducing stimulus, and secondly the induction to a state that is incompatible with anxiety, it's very important for the patient to learn how to overcome his/her anxiety either by going to a psychiatrist or from a dentist that is trained in behavior management and who focuses on this aspect. We need to get the patient relaxed as much as possible, because when they're relaxed we can expose them to their fear. It is based on the assumption that relaxation and anxiety cannot exist at the same time in an individual. You need to have the patient relaxed through relaxation techniques, and then you expose the patient to a hierarchy of fear-producing stimuli (only progressing from one to the next when they feel able) until you reach what he's afraid of.
The relaxation phase is critical and may take several visits to achieve; without a relaxation visit you will not get systemic desensitization. For true phobia, several relaxation sessions with a psychologist or a dentist who has received training in relaxation techniques may be required. A psychologist is usually preferred, the technique is useful for a child who can clearly identify their fear and who can verbally communicate. It is usually used for older children, teenagers who can communicate and know what it is they’re afraid of.
We said never show the needle to kids, but some kids have already seen the needle and they have a phobia from it, in this case we have a method by applying systemic desensitization, we probably won't use this method in our clinics, because showing a dental phobic the needle without first relaxing him is completely ineffective, so the condition is that the patient must be relaxed.
The steps in the hierarchy of fear-producing stimuli in the case of the needle:
1.) Show the child the assembled dental syringe, let him/her have a good look at it, and even let them hold it, bring it near their face.
2.) Hold it inside the mouth while it's still covered with its cap.
3.) Remove the needle guard and place it in the hand of the patient, then place it by the side of the face.
4.) Put it inside the mouth, bring it close to the mucosa in the area the injection will be given, you press it with the cap still on, then remove the guard and hold the syringe inside the mouth, place the needle in contact with the mucosa then insert some pressure.
All these are baby steps that lead to actually giving the injection, as we said we probably won't use this method, but as a general term systemic desensitization is to expose the patient time and again to his surroundings it the clinic.
10.) Negative reinforcement
It is the strengthening of a pattern of behavior by the removal of a stimulus which the individual perceives as unpleasant as soon as the required behavior is exhibited.
For example, you can ask the parents to step outside the clinic, and then tell the child that they will come back only when they stop crying. That way they know that if they stopped crying something good will happen (which is in this example their parents coming back inside) and if they don’t stop crying their parents will stay outside.
This is not considered punishment, you're not hitting or harming the child, you're trying to teach them how to act through negative reinforcement
The stimulus is applied to all actions except the required one, thus reinforcing it by the removal of a negative stimulus.
So in the previous example, no matter what the child does; crying, refusing to open his mouth, yelling…etc. we won't let his parents back in his line of sight until he does what we want him to do.
It should not be confused with punishment, which is the application of an unpleasant stimulus to inappropriate behavior.
 A question was asked: "If the child had a toy, and I took his toy away to try and get him to cooperate, is this considered as punishment?"
 Answer: This is a tricky situation, because ultimately the child is somebody's son/daughter, it's not just you and him/her so you need the consent of the parents. Therefore in front of the parents you can say I'm going to give your toy to your mom, and I won't give it back to you until you stop crying. The most important thing is getting the parents consent.

Examples of negative reinforcement:
1.) Exclusion of the parents
2.) Hand Over Mouth Exercise (HOME):

Hand Over Mouth Exercise (HOME):
It involves restraining the child in the dental chair, placing a hand over the mouth to allow the child to hear, the nose must not be covered, the dentist then talks quietly to the child explaining that the hand will be removed as soon as crying stops. As soon as this happens the hand is removed and the child praised.
If protests start again the hand is replaced, the technique aims to gain the child's attention and to enable communication to reinforce good behavior and to establish that avoidance is futile.
We should NOT use this technique, some clinicians use it but in J.U. Hospital it is not applied, but we should know about it.
It's usually used with children who are uncontrolled, sometimes the child may start crying in the dental chair, and no matter what you say to them they are not responding, we took that in such cases we temporize it. However some clinicians like to get the job done, so they apply this technique.
The doctor doesn’t approve of this technique (which is not surprising, if the child was afraid before just imagine how he'll feel after being restrained, he definitely won't be happy).
There are not many studies done on this method because it's very difficult to obtain consent, not many parents will approve of their child going through that.
The message that’s being sent to the child is that no matter what the child does; from crying, to screaming, and yelling, the procedure will get done.
Those that advocate the technique recommend it for children 4-9 years of age, younger than 4 years of age won't understand, and older than 9 are too big for this. It's done when communication is lost or during temper tantrums. Parental consent is important and the technique should never be used on children too young to understand or who are mentally and emotionally handicapped.
This is the most controversial of all behavior management techniques used by dentists, it is rarely used. There have been no studies done on the effectiveness of hand over mouth technique because of the difficulty in obtaining the ethical consent for such a study.

Exclusion of the parents:
This is less controversial than HOME, but it uses the same principles, and it's indications are the same as for hand over mouth. Parental consent is required. When inappropriate behavior is exhibited the parent is asked to leave. However parents do not like to leave their child while crying in the hands of someone they don’t know. Ideally the parent should be able to hear but be out of sight of the child. When appropriate behavior is exhibited the parent is asked to return thus reinforcing that behavior. It's not acceptable to make the parents leave the clinic completely where they have no idea what's going on with their child especially while they're crying, very few parents would agree to this. They need to be in the game with you, they need to be informed that this is a way to try to get their child to cooperate.

Protective stabilization:
The restriction of patients freedom of movement with or without the patients permission (most of the time it's without the patient's permission) to decrease risk of injury (because we're working with hand pieces and instruments that can cause injury) while allowing safe completion of treatment. The restriction may involve another human or humans (most often than not it requires more than one person), a patient stabilization device (papoose board), or a combination thereof.

The use of protective stabilization has the potential to produce serious consequences such as physical or psychological harm, loss of the child's dignity, and a violation of a patient's rights.
This is controversial, should you physically stabilize the child while doing dental work? Sometimes the parents may become impatient and will ask you to finish the procedure while the father holds his kid down, he may restrain his hands and hold his head in place and ask you to get the job done, there is a mouth probe that is inserted inside the patients mouth and this way the mouth stays open. So if his hands, legs, and head are held down you can finish the work.

It's still being used and some parents will want to hold their children down in order to just get things done. There are several clinics in this country that use this technique, when there is no access to general anesthesia, young uncontrolled children most of the time require treatment under general anesthesia, and then after the pain is relieved they start coming into the clinic for rehabilitation just for prevention measures. If the parents request to hold their child down, its ultimately up to you but it's better not to do it, and it's enough to tell the parents that you can't do this, and explain to the parents that there are other methods such as general anesthesia that will enable you to complete the procedure and will be better for the parents and the child in the long run.

Best Wishes 
Done by: Hanan Musleh

Shadi Jarrar
مشرف عام

عدد المساهمات : 997
النشاط : 12
تاريخ التسجيل : 2009-08-28
العمر : 27
الموقع : Amman-Jordan

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