behavior management(01 2011)

8/3/2019 Behavior Management(01 2011)

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BEHAVIOR MANAGEMENTBEHAVIOR MANAGEMENT

IN DENTAL PRACTICEIN DENTAL PRACTICEBy:By:Prof. SAMI ABDULKAWIProf. SAMI ABDULKAWI

Prof. in Clinical NeuropsychologyProf. in Clinical NeuropsychologyAin Shams Univ.Ain Shams Univ.

Consultant Clinical PsychologistConsultant Clinical PsychologistKAMCKAMC


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22//1313//20122012 Behavior ManagementBehavior ManagementProf. Sami AbdulkawiProf. Sami Abdulkawi

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Lecture Objectives:Lecture Objectives:

At the end of this lecture the participant should beAt the end of this lecture the participant should beable to:able to:

Describe the behavior management goals for pediatricDescribe the behavior management goals for pediatricdental patients.dental patients.

In doing this, he should be able to provide the objectives,In doing this, he should be able to provide the objectives,indications, and one example of each technique.indications, and one example of each technique.

Compare the various methods of management as to theirCompare the various methods of management as to theireffectiveness in reducing fear and pain, their influence oneffectiveness in reducing fear and pain, their influence oncommunication and learning.communication and learning.

Describe and perform techniques of Basic BehaviorDescribe and perform techniques of Basic BehaviorGuidance.Guidance.


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Dental CaseDental Case

AA 44--yearyear-- old patient arrives for his first dentalold patient arrives for his first dental

examinationexamination He is sitting in the waiting room, quietly playingHe is sitting in the waiting room, quietly playing

with some toys.with some toys.

You have no idea what he is thinking.You have no idea what he is thinking.

However, going through your mind are a lot ofHowever, going through your mind are a lot ofquestionsquestions-- Is he anxious?Is he anxious?

-- If so, how can I manage his anxiety?If so, how can I manage his anxiety?

-- What behavior management techniques are appropriateWhat behavior management techniques are appropriatefor me to use?for me to use?

-- If he needs dental treatment, what dosage of localIf he needs dental treatment, what dosage of localanesthetic is safe to use?anesthetic is safe to use?

-- Are there other pharmacologic approaches to consider?Are there other pharmacologic approaches to consider?


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The etiologies of dental fearThe etiologies of dental fear

1.1. Children often have anxiety when they experienceChildren often have anxiety when they experiencesomething newsomething new..

2.2. Previous historyPrevious history of dental or medical bad experience.of dental or medical bad experience.

3.3. Fear of painFear of pain which may be a major concern forwhich may be a major concern forchildren.children.

Children have relatively limited communication skills and areChildren have relatively limited communication skills and areless able to express their fears and anxieties.less able to express their fears and anxieties.

Their behavior is essentially a reflection of their inability toTheir behavior is essentially a reflection of their inability to

cope with their anxiety.cope with their anxiety.4.4. Parental anxietyParental anxiety:: the children of anxious parentsthe children of anxious parents areare

more likely to exhibit anxiety.more likely to exhibit anxiety.5.5. Separation anxietySeparation anxiety, distress when the parent is, distress when the parent is

removed.removed.


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Goals Regarding AnxietyGoals Regarding Anxiety

Our goal is to help child overcome hisOur goal is to help child overcome hisfear and help him realize that he can dofear and help him realize that he can doit.it.

How to achieve this goal?How to achieve this goal?

The first thing is to get a sense of comfort.The first thing is to get a sense of comfort. we show them how we do things andwe show them how we do things and when they see other children around them being workedwhen they see other children around them being worked

on.on.

Help the child know from the beginning what isHelp the child know from the beginning what isexpected of him and what he can expect from us.expected of him and what he can expect from us.

There are methods commonly used inThere are methods commonly used inpediatric dental practices (Behaviorpediatric dental practices (BehaviorManagement).Management).


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To do this ?.. the dentist mustTo do this ?.. the dentist must Establish aEstablish a relationshiprelationship based on trust with the childbased on trust with the child

to ensure compliance (the treatment alliance).to ensure compliance (the treatment alliance).

The relationship between the child, the childThe relationship between the child, the childssfamily and the dental team is afamily and the dental team is a dynamic process.dynamic process.

It may start before the patient arrives in theIt may start before the patient arrives in the

surgery.surgery. can involve written information as well ascan involve written information as well as

dialogue, voice tone, facial expression, bodydialogue, voice tone, facial expression, bodylanguage and touch.language and touch.

No one method will be applicable in all situations,No one method will be applicable in all situations,rather the appropriate.rather the appropriate.

managementmanagement technique (s) should be chosentechnique (s) should be chosenbased on the individual childbased on the individual childs requirements.s requirements.


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Factors influencing child behaviorFactors influencing child behavior

1.1. Medical history.Medical history.

2.2. Parental anxietyParental anxiety..

3.3. The Role of the parentThe Role of the parent

parents prefer to be present duringparents prefer to be present duringtreatment, especially if their child is youngtreatment, especially if their child is youngor at an initial visit.or at an initial visit.

The major concern for dentists is theThe major concern for dentists is the

potential of the parent to disrupt treatmentpotential of the parent to disrupt treatmentby inappropriate communication or byby inappropriate communication or byexhibiting anxiety themselves.exhibiting anxiety themselves.


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Factors influencing child behaviorFactors influencing child behavior

44-- CCommunication:ommunication:

A.A.Good communication is essential with allGood communication is essential with allpatients.patients.

bb-- with children the communication pathwaywith children the communication pathwayis more complex than adult patients.is more complex than adult patients.

cc-- The child, dentist, parent, and dentalThe child, dentist, parent, and dentalnurse are all potentially involved.nurse are all potentially involved.

dd-- Each member of the dental team mustEach member of the dental team mustunderstand their role.understand their role.


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Objectives or GoalsObjectives or Goals

of Behavior Managementof Behavior Management

1.1. To establish effective communication,To establish effective communication,

2.2. To alleviate patient fear and anxiety,To alleviate patient fear and anxiety,

3.3. To build a trusting relationship with theTo build a trusting relationship with thepatient.patient.

4.4. To build a positive dental attitude.To build a positive dental attitude.

All lead toAll lead to

allow the dentist to deliver quality dental careallow the dentist to deliver quality dental care promote in the patient a positive attitudepromote in the patient a positive attitude

towards dental care and oral health.towards dental care and oral health.


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Psychological ManagementPsychological Management

Behavior Modification:Behavior Modification: a form of psychological management that comes abouta form of psychological management that comes about

through the education process and is directly influencedthrough the education process and is directly influencedby communication.by communication.

Classical Conditioning:Classical Conditioning: a form of learning in which the subject establishes a newa form of learning in which the subject establishes a new

association between an outside stimulus and a responseassociation between an outside stimulus and a responsethat is a natural reflex action (involuntary).that is a natural reflex action (involuntary).

Operant Conditioning:Operant Conditioning:

a form of learning in which a new association between aa form of learning in which a new association between astimulus and a response is developed; however, thestimulus and a response is developed; however, theaction of the learner is voluntary, not a reflex.action of the learner is voluntary, not a reflex.


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What is Behavior Management ?What is Behavior Management ?

Behavior ManagementBehavior Management is:is: all of the actions and conscious inactionsall of the actions and conscious inactions

to enhance the probability people,to enhance the probability people,

individually and groups, toindividually and groups, to choosechoosebehaviors which are:behaviors which are: personally fulfillingpersonally fulfilling,,

productiveproductive, and, and

socially acceptablesocially acceptable..

(Shea & Bauer,(Shea & Bauer, 19871987).).


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22//1313//20122012 Behavior ManagementBehavior Management

Prof. Sami AbdulkawiProf. Sami Abdulkawi

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Behavior ManagementBehavior Management TechniquesTechniques

1. Basic Behavior Techniques

1.1. Modeling,Modeling,

2.2. Communicative management,Communicative management,

3.3. Nonverbal communication,Nonverbal communication,

4.4. Positive Reinforcement,Positive Reinforcement,

5.5. Negative reinforcement,Negative reinforcement,

6.6. Distraction.Distraction.

7.7. TellTell--ShowShow--Do (TSD),Do (TSD),

8.8. Hand Over Mouth (HOM)Hand Over Mouth (HOM)2. Advanced management modalities:

1.1. physical management (Immobilization),physical management (Immobilization),

2.2. aversive management, andaversive management, and

3.3. pharmacologic management (sedation & anesthesia)pharmacologic management (sedation & anesthesia)


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Behavior ManagementBehavior Management

11-- Preparatory informationPreparatory information

(psychoeducation)(psychoeducation) Strategies that have been used to decreaseStrategies that have been used to decrease

parental anxiety, such asparental anxiety, such as -- prepre--appointmentappointmentletters, may also help children.letters, may also help children.

These are usually in the form of a letterThese are usually in the form of a letterwelcoming the new patient and family to thewelcoming the new patient and family to thepractice.practice.

Such letters inform them about what willSuch letters inform them about what willhappen at the visit, give advice on preparinghappen at the visit, give advice on preparingthe child and help to reduce parental anxiety.the child and help to reduce parental anxiety.


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22-- Non verbal communicationNon verbal communication

Nonverbal communication is the reinforcementand guidance of behavior through appropriatecontact, posture, and facial expression.

This technique is critical for children withhearing impairments.

Objectives: Enhance the effectiveness of other communicative

guidance techniques Gain or maintain the childs attention and achieve

compliance Provide reassurance


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33-- Voice controlVoice control

Voice control is a controlled alteration of voiceVoice control is a controlled alteration of voicevolume, tone, or pace to influence and directvolume, tone, or pace to influence and directthe childthe childs behavior.s behavior.

This technique is ineffective for children withThis technique is ineffective for children withsevere hearing impairments.severe hearing impairments.

Young children often respond to the tone ofYoung children often respond to the tone ofvoice rather than the actual words.voice rather than the actual words.

Such techniques aim to improve attention andSuch techniques aim to improve attention andcompliance as well as to establish authority.compliance as well as to establish authority. For example, an abrupt change from soft to loud toFor example, an abrupt change from soft to loud to

gain attention of a child who is not complyinggain attention of a child who is not complying..

Voice control has been shown to decreaseVoice control has been shown to decreasedisruptive behaviors without producing longdisruptive behaviors without producing long--term negative effects.term negative effects.


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33-- Voice controlVoice control

However, it is not appropriate forHowever, it is not appropriate forchildren too young to understand.children too young to understand.

Objectives:Objectives: Gain the childGain the childs attention and achieves attention and achieve

compliance.compliance.

Avert negative or avoidance behaviorsAvert negative or avoidance behaviors

Establish appropriate adultEstablish appropriate adult--child roleschild roles


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44-- Behavior ShapingBehavior Shaping andand

Positive ReinforcementPositive Reinforcement

ReinforcementReinforcement is:is:

the strengthening of a pattern of behavior,the strengthening of a pattern of behavior, increasing the probability of that behaviorincreasing the probability of that behavior

being displayed again in the future.being displayed again in the future.

Social reinforcersSocial reinforcers include:include:

positive voice modulation,positive voice modulation, facial expression,facial expression, verbal praise, andverbal praise, and appropriate physical demonstrations of approval.appropriate physical demonstrations of approval.

Remember to:Remember to:

Identify target behaviorIdentify target behavior Select an appropriate reward for the patientSelect an appropriate reward for the patient Reward the target behavior promptly and consistentlyReward the target behavior promptly and consistently Ignore undesirable behaviorIgnore undesirable behavior


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UnUn--rewarded responses tend to berewarded responses tend to beextinguished when appropriateextinguished when appropriatebehavior is immediately reinforced.behavior is immediately reinforced.

ObjectiveObjective::

Reinforce desired behaviorReinforce desired behavior..

The technique is useful for all patientsThe technique is useful for all patientswho can communicate. There are nowho can communicate. There are nocontraindicationscontraindications


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Positive reinforcementPositive reinforcement technique involvestechnique involvesthe control of behavior through the use ofthe control of behavior through the use of

appropriate feedback.appropriate feedback.

Anything that the child finds pleasant orAnything that the child finds pleasant orgratifying can act as a positive reinforcer,gratifying can act as a positive reinforcer,stickers, tokens or toys are often used atstickers, tokens or toys are often used atthe end of a successful appointmentthe end of a successful appointment


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55-- Negative ReinforcementNegative Reinforcement

Negative reinforcement has also been used in dentalNegative reinforcement has also been used in dentalpractice.practice.

It is the strengthening of a pattern of behavior byIt is the strengthening of a pattern of behavior bythethe removal of a stimulusremoval of a stimulus which the individualwhich the individualperceives asperceives as unpleasantunpleasant (a negative reinforcer) as(a negative reinforcer) as

soon as the required behavior is exhibited.soon as the required behavior is exhibited.

It should not be confused withIt should not be confused with punishmentpunishment, which, whichis theis the applicationapplication of an unpleasant stimulus toof an unpleasant stimulus to

inappropriate behavior.inappropriate behavior. Well known examples in dental practice are HandWell known examples in dental practice are Hand

Over Mouth (HOM) and Selective Exclusion of theOver Mouth (HOM) and Selective Exclusion of theParent (SEP).Parent (SEP).


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66-- ModelingModeling

The technique is based on the psychologicalprinciple that people learn about theirenvironment by observing others behavior,using a model, either live or by Video to exhibitappropriate behavior in the dental environment.

This may demonstrate appropriate behavior viaa third party, decrease anxiety by showing apositive outcome to a procedure a child requiresthemselves, and illustrate the rewards forperforming appropriately.

For best effects models should be the same ageas the target child, should exhibit appropriatebehavior and be praised.


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77-- DistractionDistraction

Distraction is the technique of diverting the childsattention from what may be perceived as an unpleasantprocedure.

This can be done through: talking, asking the parent to play with the child,

using headphones to play music, or allowing the child to watch a videotape or DVD.

Cartoons have been shown to reduce disruptive behaviorsin children when combined with reinforcement, that iswhen children knew the cartoon would be switched off if

they did not behave.

The dentist who talks while applying topical paste andadministering local anaesthetic is also using distractionwith words.


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88-- Systematic desensitization (SD)Systematic desensitization (SD)

This technique helps individuals with specific fears orphobias overcome them by repeated contacts.

A hierarchy of fear-producing stimuli is constructed, andthe patient is exposed to them in an ordered manner,starting with the stimulus posing the lowest threat.

In dental terms, fears are usually related to a specificprocedure such as use of local anaesthetic. First, the patient is taught to relax, and in this state exposed

to each of the stimuli in the hierarchy in turn, only progressingto the next when they feel able.

For true phobias several relaxation sessions with apsychologist or dentist who has received training inrelaxation techniques may be required..


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88-- Systematic desensitization (SD)Systematic desensitization (SD)

A similar approach can be used for children who havehad a negative experience in the past.

The technique is useful for a child who can clearly identifytheir fear and who can verbally communicate.

It is based on the understanding that relaxation andanxiety cannot exist at the same time in an individual.

The relaxation phase is critical and may take severalvisits to achieve.

The best known method of relaxation is based onprogressive muscle relaxation, usually starting with the

feet and working up the body, coupled with slowcontrolled breathing..


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Systematic desensitization hierarchy

for phobia related to

dental local analgesic injections.1. Instructions on muscle relaxation and or relaxation

breathing.2. Explanation of components of local anaesthetic

equipment.3. Look at an assembled dental syringe.4. Explanation and demonstration of effect of topical

anaesthetic.5. Hold an assembled dental syringe on the palm of the

patients hand.6. Hold an assembled dental syringe by the patients face.7. Hold an assembled dental syringe inside the patients

mouth.

8. Hold an assembled dental syringe (needle guardremoved) on the palm of the hand.9. Hold a syringe (guard removed) by the side of the face.


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Systematic desensitization hierarchy for phobiaSystematic desensitization hierarchy for phobia

related to dental local analgesic injectionsrelated to dental local analgesic injections..

11.11. Hold the syringe inside the mouth (guard removed).Hold the syringe inside the mouth (guard removed).12.12. Replace the guard and hold the end of the syringe againstReplace the guard and hold the end of the syringe against

the mucosa overlying the injection site.the mucosa overlying the injection site.13.13. Press the syringe (guard in place) over the injection site.Press the syringe (guard in place) over the injection site.

14.14. Place topical anaestheticPlace topical anaesthetic15.15. Remove the guard and hold the syringe inside the mouth.Remove the guard and hold the syringe inside the mouth.16.16. Place the needle in contact with the mucosa over thePlace the needle in contact with the mucosa over the

injection site.injection site.17.17. Place the needle in contact with the mucosa and insertPlace the needle in contact with the mucosa and insert

some pressure.some pressure.

18.18. Hold the needle in contact with the mucosa and insertingHold the needle in contact with the mucosa and insertingenough pressure for the needle to penetrate the mucosa.enough pressure for the needle to penetrate the mucosa.19.19. As inAs in 1414, but deliver a minute amount of local analgesic, but deliver a minute amount of local analgesic

solution.solution.


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99-- TellTell--ShowShow--Do (TSD)Do (TSD)

This technique is widely used to familiarize a patient with a new

procedure.

TellTell--showshow--dodo involves:involves:1.1. TellTell:: verbal explanations of procedures in phrases appropriate to

the developmental level of the child..

1.1. Show:Show: demonstrations of the visual, auditory, olfactory, and tactile

aspects of the procedure in a carefully defined, non threateningsetting (slow handpiece on a finger).

2.2. Do:Do: without deviating from the explanation anddemonstration, completion of the procedure (in this case apolish).

Objectives:Objectives: Teach the child about important aspects of the dental visit andTeach the child about important aspects of the dental visit andfamiliarize the child with the dental setting.familiarize the child with the dental setting.

Shape the childShape the childs response to procedures through desensitizations response to procedures through desensitizationand welland well--described expectationsdescribed expectations


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99-- TellTell--ShowShow--Do (TSD)Do (TSD) The technique is useful for all patientsThe technique is useful for all patients

who can communicate. There are nowho can communicate. There are nocontraindications.contraindications.

The tellThe tell--showshow--do technique is useddo technique is usedwith communication skills (verbal andwith communication skills (verbal andnonverbal) and positive reinforcement.nonverbal) and positive reinforcement.

Emotive or negative words are avoidedEmotive or negative words are avoided

An effective way of reducingAn effective way of reducinganticipatory anxiety in new childanticipatory anxiety in new childpatients.patients.

Remember to:Remember to: Use words the child can understandUse words the child can understand Introduce the simplest procedures firstIntroduce the simplest procedures first Explain the procedures at the childExplain the procedures at the childs levels level

Involve the childInvolve the child


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1010-- Hand Over Mouth (HOM)Hand Over Mouth (HOM)

HOMHOM involves restraining the child in theinvolves restraining the child in thedental chair, placing a hand over the mouthdental chair, placing a hand over the mouth(to allow the child to hear). The nose must(to allow the child to hear). The nose mustnot be covered.not be covered.

The dentist then talks quietly to the childThe dentist then talks quietly to the childexplaining that the hand will be removed asexplaining that the hand will be removed assoon as crying stops.soon as crying stops.

As soon as this happens the hand isAs soon as this happens the hand isremoved and the child praised.removed and the child praised.

If protests start again the hand isIf protests start again the hand isreplaced.replaced.

The technique aims to gain the childThe technique aims to gain the childssattention and enable communication, andattention and enable communication, andreinforce good behavior.reinforce good behavior.


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