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Pedodontics
5ª stage
Dr. Aseel Haidar
Management of Children Behaviors
Behavior Management
The foundation of practicing dentistry for children is the ability to guide them
through their
dental experiences. The dental health team effectively and efficiently performs
treatment to the
child by the means of behavior management, so our aim is to create a positive
dental attitude to
the children. They are basically about communication with the pt. and his parents
and about
educating the child how to behave in dental clinic to decrease the anxiety and fear
and to promote
understanding to achieve good oral health.
Individuals usually differ. Therefore, the appropriate management should be chosen
depending on the individual's needs, every practitioner integrates his/her
personality on the basic
psychological principles in managing children, so what works with one may not
necessarily work
with the other
Definitions
* Behavior: It is an observable act, which can be described in similar ways by more
than one person.
• Child dental management: it is the process of leading a child through a dental
appointment; it is the means by which a course of treatment for a young patient
can be completed in the shortest possible period, while at the same time ensuring
that he will return for the next course willingly.
Behavioral Pedodontics
A professional goal is to promote positive dental attitudes and improve the dental
health
of society. Logically, children are keys to the future. Since childhood experience
plays an
important role in forming the adult behavior, proper behavior management from the
early stages
will help in the development of a proper oral health attitude among individuals
throughout life.
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
the dentist, the patient, and parents or caregivers. This relationship, known as
the pediatric
dentistry treatment triangle.
Because these individuals and their relationships cannot be segregated from
external
influences, the triangle is encircled by society. Management methods acceptable to
society and
the litigiousness of society have been factors influencing treatment modalities.
The child is at the
apex of the triangle and he is the focus of attention of both the family and the
dental team.
Baghdad College of dentistry
2022
Although mothers' attitudes have been shown to significantly affect their
children's behaviors in
the dental office, the roles of families have been changing, and the entire family
environment
must be considered. Because changes are constantly occurring within each
personality, one must
remember that there is an ever-changing, dynamic relationship among the comers of
the
triangle-the child, the family, and the dental team. The arrows placed on the lines
of
communication remind us that communication is reciprocal.
The relation here is not just you and the pt. it's a three way process, other say
it's 4 way
process (you, the pt., his parents, and dental team) it's a dynamic process that
starts before the
pt. arrives and it involves dialogue, voice tone, facial
Society
expressions, body language, and touch. Some people do not
Child
like to use the word management. Because they think, it is a
little harsh, so they use "Behavioral Guidance" instead,
because it guides the child toward communication and
Society
education, using a continuous interaction involving the dental
Parent/caregiver
Dentist/dental team
health team, the dentist, the patient and his parents leading to a
good dental treatment and creating a positive experience to the
48 305
child himself.
The goals of behavior management are:
• To establish communication with the child and the parents.
• Alleviate fear and anxiety to provide a relaxing and comfortable environment for
the dental
team to work in, while treating the child
• Deliver quality dental care
• Build a trusting relationship between dentist, parent and child
• Promote child's positive attitude towards oral/dental health.
FUNDAMENTALS OF BEHAVIOR MANAGEMENT
1) The team attitude
2) Organization
3) Positive approach
4) Truthfulness
5) Tolerance
6) Flexibility
PEDIATRIC DENTAL PATIENTS]
Although there may be expectations for children's skills based upon chronological
age,
the practitioner must assess the individual child's understanding and be familiar
with the family
environment. Differences in genetics, personality, and experience influence the way
the child
engages with his surroundings. If influences are in harmony, healthy development of
the child
can be expected; if they are dissonant, behavioral problems are almost sure to
ensue. Key to a
practitioner's interaction with a child is remembering that each child is unique
and exists in the
context of his family.
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Pedodontics
5* stage.
Child development
Child development involves the study of all areas of human development from
conception
through young adulthood. It involves more than physical growth, which often implies
only an
increase in size. Development implies a sequential unfolding that may involve
changes in size,
shape, function, structure, or skill.
Major area of development
1. Physical development
Physical development is a term used to describe the child's total physical growth
and
efficiency from the moment of conception until adulthood together. The broad area
of physical
development involves changes that occur in children's size, strength, motor
coordination,
functioning of body systems, and so forth.
Because a child's physical development is relatively independent of other major
areas of
development, subareas of physical development must be relatively independent.
Child's
coordination cannot be judged by physical size and the physical strength is not
related to dental
development.
Relating key aspects of development to chronologic ages has led to the
establishment of
developmental milestones as a means of assessing individual children. Each child is
unique and
may develop at varying rates relative to their same-aged peers, For example, one
child may
present with strong motor skills but less well-developed language, while this may
be the opposite
for another same-age peer.
Typical personality characteristics related to specific chronologic ages that have
relevance to
dentistry are listed below which can help in the development of behavioral guidance
strategies:
Age-Related Psychosocial Traits and Skills for 2- to 5-Year-Old Children
TWO YEARS
Geared to gross motor skills, such as running and jumping
Likes to see and touch
Very attached to parent
Plays alone; rarely shares
Has limited vocabulary; shows early sentence formation
Becoming interested in self-help skills
THREE YEARS
Less egocentric; likes to please
Has very active imagination; likes stories
Remains closely attached to parent
FOUR YEARS
Tries to impose powers
Participates in small social groups
Reaches out— expansive period
Shows many independent self-help skills
Knows "thank you" and "please"
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Pedodontics
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FIVE YEARS
Undergoes a period of consolidation; deliberate
Takes pride in possessions
Relinquishes comfort objects, such as a blanket or thumb
Plays cooperatively with peers
From these data, two pieces of information about development milestone: 1. the
average age at which a child acquires particular skills. 2. The normal range of
ages at which the
skill is acquired
Knowing the general developmental principle reminds the clinician to consider the
ability or readiness of the individual to perform a given task.
Q: How can the dentist manage a two years old child?
Social development
It include both interpersonal relationships and independent functioning skills. An
important process for dentists is the child's growth toward independent
functioning. For their
survival, infants are dependent on others to clothe, feed, and nurture them. As
children grow and
their ability to care for themselves improves, they gain social independence.
Autonomy is an
increasingly important consideration in health care for pediatric patients.
Recognizing that the change from functional dependency to functional autonomy is
a normal process in social development that can assist the dentist. While it is the
right of patients
to have autonomy over their health care decisions, a pediatric patient generally
does not have
legal authority to consent to or refuse health care services. Most minors either
have limited
capacity for health care decision-making or have not established independence.
Children should
not, however, be excluded from treatment decision-making processes. When the
pediatric patient
begins to demonstrate an ability to think logically and understand outcomes, he
should be
involved in the informed consent/assent process. Assent is an interactive process;
engaging the
child demonstrates a respect for his emerging autonomy and may promote confidence
building
and cooperation.
3. Intellectual development (mental development)
It is the employed quantified mental abilities in relation to chronologic age. It
led to
the concept of the intelligence quotient (IQ), which was measured by tasks
examining memory,
spatial relationships, reasoning, and a variety of other primary mental skills.
This enabled an
examiner to determine a child's mental age based on performance. The basic Binet IQ
formula
used is:
IQ= (mental age/ chronological age) × 100
Individuals with intelligence deficiency or intellectual disability may require
special behavior guidance. For anxious patients having an intellectual disability
but with
cooperative potential, desensitization to the dental setting in incremental steps
prior to the initial
appointment may prove beneficial.
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Pedodontics
5 stage
The Wechsler Intelligence Scale for Children (WISC), developed by David
Wechsler, is an individually administered intelligence test for children aged 6
years- 16 years and
11 months. The WISC-V takes 45-65 minutes to administer and generates a Full Scale
IQ
(formerly known as an intelligence quotient or IQ score) which represents a child's
general
intellectual ability. The WISC is used not only as an intelligence test, but also
as a clinical tool.
Some practitioners use the WISC as part of an assessment to diagnose attention-
deficit
hyperactivity disorder (ADHD) and learning disabilities, for example. This test
provides a broad
assessment of general intellectual functioning and school-related abilities.
Wechsler intelligence
scales are available for preschoolers (Wechsler Preschool and Primary Scale of
Intelligence, or
WPPSI, children (Wechsler Intelligence Scale for Children-Revised, or WISC-R), and
adults
(Wechsler Adult Intelligence Scale, or WAIS).
What are the difference between Anxiety, Fear and Phobia?
Fear (Apprehension based on history): It is a primal emotion which stems from a
recognized source developed to protect the individual from harm and self-
destruction it has safety
value when given proper direction and control. The subject is able to pinpoint what
he/she is afraid
of e.g. fear of needle. Fear sets in a series of physiological responses to prepare
a subject for
fight/flight response.
Anxiety (Fear of the unknown): It is one of the primary emotions acquired soon
after
birth. It is a personality trait and is apprehension, tension or uneasiness that
stems from
anticipation of danger, the source of which is largely unknown or unrecognized.
There is no clear division between fear, anxiety and other responses to stress.
Fear and
anxiety can intensify pain or misattribute pain e.g. Events which are not pain
provoking can be
perceived as painful.
Phobia (Pathological fear): It is persistent, excessive, unreasonable fear of a
specific
object, activity or situation, attached to a certain stimulus. It is deep seated
and is provoked by
any stimulus which resembles the original episode.
Fear is best understood within a multifactorial context of personal, environmental,
and
situational factors in combination with the child's development and intelligence.
Fearfulness is a
personality trait often associated with temperament, shyness and negative mood.
Most of the time
parents instill the fear of dentistry in their children as a means of punishment.
Fear should be
channeled in the correct direction such as those that causes harm to the child's
existence or
wellbeing. Children should be taught that dental office is not a place to fear, and
the parents
should never employ dentistry as threat or punishment. Using it in this manner
creates fear of
dentistry or dentist. On the other hand if the child has become attached to the
dentist, fear of loss
of his approval may have some value in motivating the child for dental treatment.
The child's fears change with age:
Two Years Old
They are in precooperative stage of lacking cooperative ability. Solitary play is
preferred, as child has not yet
learned to play with other children. Fear or anxiety of this age group is fear of
falling, sudden jerky movements,
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bright lights, separation from the parents and fear of strangers.
Three Years Old
Communication is easier. Child has great desire to talk and often enjoy telling
stories. Fear of this age group
is fear of strangers. It is the right time to introduce the child to dentistry.
This is also the appropriate time to begin
any preventive procedures.
Four Years Old
They are usually listeners to explanations with interest and normally responsive
too verbal directions. They
usually have lively minds and may be great talkers, although they tend to
exaggerate in their conversation.
In some situations, they may be defiant. There is increased ability to evaluate
fear-producing stimulations.
Intelligent children display more fear, may be because of greater awareness of the
danger and reluctance to accept
verbal assurance without proof.
Fears of this age group: Fear of falling, of noise and of strangers is lessoned.
Fear of bodily injury is present.
Prick of hypodermic needle or sight of blood produces increased response dis
proportionate to that of pain.
Fears of 4-8 years old
Intelligent children display more fear because of their greater awareness of danger
and reluctance to accept verbal
Fears of 9 years of age
Fear is usually associated with personal failures and social peer situations. Child
can usually resolve fears
of dental procedures if dentist explains and reasons will. Child has also learned
to tolerate unpleasant situations
and has marked desires to be obedient, carrying frustrations well. The child
develops considerable emotional
control. However, objects to people making light of his suffering, bullying,
injustice or ridiculing whether it is
from a friend or a dentist.
Fears are of two types:
A child may experience two types of fear during dental treatment:
1. Objective fears
2. Subjective fears
Objective fears: These are acquired objectively or those produced by direct
physical stimulation
of the sense organs (seen, felt, smelt, or contacted) but not of parental origin,
which are
disagreeable and unpleasant in nature.
• Fears from previous unpleasant contact with dentistry
• Unrelated experiences like repeated hospitalization leading to fear of uniforms
worn by dental
team or even characteristic smell of hospital, drugs or chemicals associated with
unpleasantness
arouse fear
Subjective fears: These are based on the feelings and attitudes suggested to the
child by others
without the child personally experiencing them. These are imitative, suggestive or
imaginative
fears. Suggestive fears are acquired by imitation by observation of others. These
imitative fears
are transmitted while displayed by others (parent) and acquired by the child
without being aware
of it. They are generally recurrent, deep seated and are difficult to eradicate.
Displayed emotion
in parent's face creates more impression than verbal suggestions. Even a tight
clenching of the
child's hand in dental office while undergoing dental treatment crates fear in
child's mind about
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dental treatment. These fears also develop from friends, playmates, reading books
and periodicals,
watching media and theater and depend on repetition.
**Value of fear: Fear lowers the threshold of pain so that every pain produced
during dental
treatment becomes magnified.
Since our aim is to reduce anxiety, what's dental anxiety? It's a vague, unpleasant
feeling accompanied by appropriation that something undesirable is about to happen.
Dental
anxious children are more sensitive to dental pain. The word anxiety differs from
the word fear,
in Fear you know what you are afraid of (more specific) in anxiety it's (more
generalized). An
old American study had showed that visiting dentists is rank 4 that causes anxiety
to people
behind, snakes, heights, and storms, so people don't really like visiting us. The
most procedure
that causes anxiety is local anesthesia, and then the sound of the drill (hand
pieces).
2: How can we tell that someone is anxious?
1. Physiological manifestation (physiologic and somatic sensation) Perspiration
palpation, breathlessness, and
anything that affects body function.
2. Cognitive features he loses his ability to focus, that's exactly what happens to
us during exams.
3. Behavioral features it's like because you're anxious you start not going to the
dentist, you start avoiding or
postponing the dental appointment.
2: How do you measure anxiety?
By measuring the 3 manifestation that we talked about.
VARIABLES INFLUENCING CHILDREN'S DENTAL BEHAVIORS
The key to successful outcomes (i.e., cooperation, relief of anxiety, completion of
quality care,
development of a trusting relationship) is an appropriate assessment of the child
and family to prepare them to
participate actively in a positive manner in the child's oral health care.
Dentistry has had some difficulty
identifying the stimuli that lead to misbehavior in the dental office, although
several variables in children's
backgrounds have been related to it. Those variables are of two types:
1. Major variables
2. Minor variables
1. Major variables
(1) Parental anxiety
Children when they are very young, they lear everything from their parents, that is
what we called
(primary socialization), it lasts for life long, but its effect is reduced when the
children go to the school and we
call it here (secondary socialization), it is an ongoing and gradual process, so
parents can shape their children's
attitude toward oral health.
The importance of the maternal anxiety has been reported and recognized for over
100 years, especially
for those less than 4 years old. Parents are also capable of predicting their
child's behavior. They can pretend if
he is going to cooperate or not, and it's well documented, if the child's mother is
anxious, or she can't even look
while we're doing the treatment we can ask another member to come with the child to
the clinic, so if the parents
are afraid of dentists the child of course will be afraid too. In the past, it has
been customary for mothers, more
often than fathers, to accompany children to the dental office. Children respond
with tension and fear primarily
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because of the way dental experiences have been described to them. The problem of
dental fear is not specific to
dental situations or procedure. The behavior of a child is found to be directly
proportional to the level of parental
anxiety in which a significant correlation between maternal anxiety and a child's
cooperative behavior at the first
dental visit. Children of mothers with high anxiety levels exhibit more negative
and uncooperative behavior. High
anxiety on the part of parents tends to affect their children's behavior
negatively. Children of all ages can be
affected by their mothers' anxieties but the effect is greatest with those younger
than four years of age. This might
be anticipated because of the child-parent symbiosis that begins in infancy and
gradually diminishes.
(2) Parenting Styles
There is a close relationship between parenting styles (patterns of behavior that
parents use to interact
with their children) and children's behavior. There are three styles of parental
control: permissive coluis,
authoritarian Lus, and authoritativese: l,.
Mothers who allowed autonomy and who expressed affection had children who were
friendly and cooperative.
Conversely, punitive or depressed mothers and those who ignored their children did
not exhibit these positive
behavioral characteristics. An association between parenting styles and dental
anxiety and behavior problems was
limited to preschool children without dental phobia at the first dental visit.
Children with authoritative parents
were found to exhibit more positive behavior than those with permissive and
authoritarian parents.
(3) Toxic Stress
Stress is first experienced in utero and will recur throughout life. Although
stress produces some minor
physiologic changes, it is normal and necessary for survival. Stress that continues
over a prolonged period and
has lifelong effects is termed toxic stress. Toxic stressors include child
abuse/neglect, chronic exposure to drugs
or violence in the home, and parental depression or mental illness. Economic
hardship is a stressor experienced
by many families.
(4) Medical experience
A child who have had a negative experience associated with medical treatments (a
lot of surgeries and a
lot of appointments) will be anxious of dental treatment even though they didn't
try it, or maybe a negative
experience from previous bad dental visit. Children with pleasant past medical
experiences are more likely to be
cooperative; but past experience of pain or negative attitude of the child towards
physician results in a negative
behavior in the dental operatory. The emotional quality of past visits rather than
the number of visits is significant.
The behavior of children with special health care needs may differ from that of
healthy children. Those with
chronic medical conditions (without developmental delay) can become "adultified."
Because of recurring medical
experiences, they may become accustomed to the health care setting and behave
"better" than expected.
Pain during previous health care visits is another consideration in a child's
medical experiences. The
pain may have been moderate or intense, real or imaginary. Parental beliefs about
past medical pain are
significantly correlated with their children's cooperative behavior in the dental
environment. Previous surgical
experiences adversely influence behavior at the first dental visits, but this was
not the case in subsequent visits.
(5) Awareness of dental problems
When a child came to the dental clinic with cellulites, with pain, and he didn't
sleep the whole night, his
first dental visit will be anxious, because he knew that something will going to
happen. Ideally, we prefer to see
the child for the first time for checkup, hence, children who know they have a
dental problem, exhibit more
negative behavior at the first dental appointment. Some children visit the dentist
when they are made aware of an
existing problem The problem may be as serious as a chronic dental abscess or as
simple as extrinsic staining of
the dentition. However, there is a tendency toward negative behavior at the first
dental visit when the child
believes that a dental problem exists which is likely to make them more
apprehensive as the question "what will
be done" comes in their minds. Concern about the presence of caries may also lead
to missed appointments. The
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significance of this variable provides the dentist a good reason for educating the
parents regarding the value of
having the child's first visit prior to any dental problem.
2. Minor variables
(1) Socio-economic status of the family directly affects child's attitude toward
the values of the dental health
process. Those of low socio-economic class, below average education, have a
tendency to attend dental needs
when symptom dictates. These families harbor anxiety from dental treatment and
these children take on these fear
and tend to be less co-operative.
2) Position of the child in the family (rank of the child,
The older child may become more anxious than children born later while middle child
is usually more
outgoing and suggestible because he use his older sibling and parent as behavior
pattern to follow.
(3) Child gender
The responses of children to the dental environment are diverse and complex. The
clear effect of the child
gender on behavior can be seen in the dental environment for example boys are
expected to be brave stronger
than girls (boy act as a man and does not cry). Girls exhibited more dental anxiety
and dental behavior
management problems than did boys.
(4) Child age
There different types of fear at different ages, like in 2-4 years fear of
imaginary creatures and small animals
then 4-6 years start social and school fear. Fear related to injury, death and so
on is shown in those 6 years to
adolescent.
5) Contemporary influences include social experiences,
attending nursery school and peer interactions
The experiences of a child during formal learning at school, summer camps or peer-
interactions may be of
help to the dentist in determining their level of cooperation. Those attend nursery
school cooperate more with the
dental procedure. Communication technologies and media also have a strong influence
on the child's behavior.
6) Modeling or imitation
It can be considered as the most effective means to introduce the child to
dentistry, also it is effective for
patients who have no previous dental visit
Some general consideration of pediatric patients' management:
1. Always call the patient by his (first/ nick) name.
2. Direct the conversation toward the child whenever possible.
3. Talk at the child's level (physically and mentally).
4. Avoid quick and sudden movements while performing the procedure.
5. Avoid fear promoting words.
6. Communicate with the patient, but once the treatment starts you need to use
short commands.
7. Admire and praise the good behavior, because children like to please adults.
8. Keep self-control all the time, it's not acceptable to lose it, especially while
dealing with the pediatric or
handicapped patients.
Some factors that might contribute to the child's behavior (related to the
dentist):
1. Scheduling: When to see the patient is very important. Most children are fresher
in the morning, we prefer
see them in the morning specially pre schooled ones, and we prefer same age group
to be there at the same period,
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so they will be comfortable when they see children who are from their age group,
another thing is how much will
they wait? Because waiting too much in the reception area leads to tiredness and
restlessness.
2. Appointment length: new researches suggested to treat each (Quadrant) in each
appointment (ex: to treat
The 6+E+D at one appointment) creating less numbers of appointments, usually the
patient loses his concentration
if the appointment is more than 30-45 minutes). On the other hand, one clinical
study stated that the length of the
appointment does not affect the behavior negatively and another one stated that it
affects the behavior positively.
3. Dental Attire: Some Pediatrics have a negative experience toward the white coat
and the mask, especially
those who were under GA, and this makes their management harder, so some pediatric
dentists tend to wear
colorful clothes, but some of them refuse that because they say it is less
professional, thus "the dental attire" is a
personal choice. Recently, it had been found that adding attractive colors to the
pediatric dental clinic and the
incorporation of different colors in the dental clinic and dentist's attire could
help to reduce dental anxiety.
of Dentis
Baghdad College
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