BEHAVIOR MANAGEMENT

BEHAVIOUR MANAGEMENT “It is the means by which the dental health team effectively & efficiently performs treatment for a child & at the same time instills a positive dental attitude” -WRIGHT (1975) Classified as: Non-pharmacological Pharmacological

Non-pharmacological behaviour management Communication Behaviour modification(shaping) Pre- appointment behavior modification Behaviour management

Communication Universally applicable tool It is the basis for establishing a strong relationship with the child patient. Helps in completion of dental procedures and development of a positive attitude in children. Should be initiated at the time of entry of the child into dental office and continued through the entire treatment time.

Communication TYPES: Verbal- by speech Non-verbal- in the form of body language, eye contact, smile, expressions, Touching, patting etc Both verbal and non-verbal

Communication Words chosen should be pleasant and expressing concern Patient should be addressed by his name Use of euphemisms -euphemisms is substitute words which can be used in presence of children. Eg: raincoat for rubberdam.  

Behaviour Modification DEFINITION: BEHAVIOR MODIFICATION IS DEFINED AS ” THE ATTEMPT TO ALTER HUMAN BEHAVIOR & EMOTION IN A BENEFICIAL MANNER ACCORDING TO THE LAWS OF MODERN LEARNING THEORY”

Behaviour Modification It involves use of reinforcers that on being learned change child’s behavior to an appropriate form. Based on stimulus-response theory. It is a step by step technique to make the child involved in dental therapy

Behaviour Modification It involves three techniques: DESENSITIZATION MODELLING CONTINGENCY MANAGEMENT

Behaviour Modification DESENSITIZATION The concept comes from “systemic desensitization” used to reduce anxiety in patients by behavior therapists. Patient learns to replace anxiety by relaxation

Behaviour Modification DESENSITIZATION Joseph Wolpe has suggested that in place of imaginery scenes, real life contacts can be effective in a dental situation. The method employed is called TELL-SHOW-DO Introduced by Addelston Involves telling, showing of stimuli in increasing order of fear, followed by doing the procedures. Language chosen should be simple The situation is presented to the child slowly and repeatedly

Behaviour Modification DESENSITIZATION Indications: Initial visit Subsequent visits for every new interaction of the child Apprehensive child due to previous information . Effective in children above 3 yrs of age Begins from initial entry till completion of the procedure The heirarchy of events may be decided by the dentist for the individual patient

Behaviour Modification MODELLING: The basic procedure involves allowing the patient to observe one or more individuals who demonstrate appropriate behaviors in a particular situation The model may be real or symbolic(posters) Was introduced by BANDURA

Behaviour Modification MODELLING: Steps- Gain attention of the patient Desired behavior is modeled Physical guidance may be needed Reinforcement of guided behavior Reinforcements for appropriate behaviors without modelling

Behaviour Modification MODELLING: It is effective when : Observer is aroused Model has higher status and prestige Associated with positive consequences

Behaviour Modification CONTINGENCY MANAGEMENT It is a method of modifying the behavior of children by presentation or withdrawal of reinforcers Reinforcers by definition increase the frequency of a behavior Types of reinforcers: Positive: presentation of which increases behavior Negative: withdrawal of which increases behavior

Behaviour Modification CONTINGENCY MANAGEMENT Can also be classified as Social reinforcers-praise, facial expressions, physical contact Material reinforcers- toys, games. Sweets should not be given. Activity reinforcers- seeing a movie, watching tv,outdoor games,etc

Preappointment preparation It involves preparing the child as well as the parents for the forthcoming dental visit. This can be done by: Messages in the form of letters or emails by showing videotapes, audiovisual aids and live models.  

Behaviour Management audioanalgesia Also called as WHITE NOISE Involves providing a sound stimulus of such intensity that the patient finds it difficult to attend to anything else.

Behaviour Management Hypnosis Also called as “suggestion therapy” Technique of producing altered state of consciousness without the use of pharmacological agents. Very rarely used in dentistry.

Behaviour Management coping Children respond to stressful situations by coping. It includes an individual’s internal and emotional processes and his external behavioral responses. The way the patient copes with his fears determines the type of patient he is.

Behaviour Management coping Mechanisms: By thinking of something else- “Distraction” Verbalizing fears to others Preferring to be with others, say, mother- this is called “employing affiliative behavior” “Mental rehearsal”- going over in one’s mind in advance the sequence of anticipated events and reappraising the threats involved.

Behaviour Management relaxation It involves a series of basic exercises which the patient practices at home and may require several weeks to months to learn. Therefore seldom used by clinicians.

Behaviour Management Aversive conditioning Aversive conditioning is the extension of overall behaviour guidance designed to facilitate the goals of communication, cooperation & delivery of quality oral health care in difficult children. It includes three practices: Voice control Hand-over-mouth exercise (HOME) Physical restraint/Treatment immobilization

Behaviour Management Aversive conditioning Voice control Voice control Voice control is a controlled alteration of voice,volume, tone,or pace to influence & direct the patients behaviour . Parents unfamiliar with this technique may benefit from a prior explanation to prevent misunderstanding OBJECTIVES: To gain patient’s attention & compliance. To avert negative or avoidance behaviour. To establish authority

Behaviour Management Aversive conditioning Hand over mouth exercise 2. Hand-over-mouth exercise (HOME) popularized by : EVANGELINE JORDAN OBJECTIVES: To redirect child's attention enabling communication To extinguish excessive avoidance behavior To reduce the need for sedation or G.A . INDICATIONS: For uncooperative child A healthy child who is able to understand verbal commands & cooperate , but exhibits negative behaviour

Behaviour Management Aversive conditioning Hand over mouth exercise CONTRAINDICATIONS: Child under 3 yrs of age Special child (physically, emotionally & mentally compromised) Child with airway obstruction or mouth breather.

Behaviour Management Aversive conditioning Hand over mouth exercise MODIFICATIONS: HOM with airway unrestricted HOM with airway restricted (HOMAR) Towel held over nose & mouth Dry towel held over nose & mouth Wet towel held over nose & mouth

Behaviour Management Aversive conditioning Physical restraint 3. Physical restraint/Treatment immobilization It is the direct application of physical force to a patient with or without the patient’s permission to restrict his or her freedom of movement. It may be: Active: Performed with restraining device Passive: Performed without restraining device

Behaviour Management Aversive conditioning Physical restraint OBJECTIVES: To eliminate unwanted movement. To protect patient, staff or dentist from injury To facilitate quality dental treatment. INDICATIONS: A patient who requires immediate diagnosis treatment & can’t cooperate When the safety is at risk Child who is becoming tired from long appointments A sedated pt who requires limited stabilization Stubborn child

Behaviour Management Aversive conditioning Physical restraint PRECAUTIONS: Tightness & duration of the stabilization must be monitored The stabilization must not restrict circulation Stabilization should be terminated as soon as possible in a patient who is experiencing severe stress  

Behaviour Management Aversive conditioning Physical restraint TYPES OF RESTRAINTS: FOR BODY: Pedi wrap Papoose board Sheets Beanbag with straps Towel & tapes FOR EXTREMITIES: Velcro straps Posey straps

Behaviour Management Aversive conditioning Physical restraint FOR HEAD: Head positioner Forearm body support Extra assistant FOR MOUTH: Mouth blocks Banded tongue blades Mouth props Finger guard or interocclusal thimble

Behaviour Management Implosion Therapy Child patient is flooded with so many stimuli that he has no other option than to face it, until the negative behavior disappears. It may include HOME, voice control, physical restraints.

Behaviour Management Retraining employed in case of children presenting negative behavior, with bad experience in previous dental visits, or improper peer or parental orientation. The child presents such behavior due to STIMULUS GENERALISATION, where similarities in stimuli generate similar responses. In retraining, we make the child DISCRIMINATE between old and new stimuli, The older response gradually diminishes - this is known as RESPONSE EXTINCTION.  

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