11/3/2014

Natalie O. Ford, DMD

Children are NOT Little Adults!

11/3/2014

Parental
Factors

Attitude of
dentists

Worse
Negative
parenting
Limit setting
Dentists less
assertive in
management style

Society

Mental health
rather than
discipline
Unacceptable
behavior
management
techniques

Violence in society
Multicultural
Divorce (26% in 2
parent households)

The Changing
Landscape

A Mothers Observations
Not always
objective

Mothers seem
surprised at
childs poor oral
health
{sometimes}

Mothers tend to
underrate all
negative
behaviors

Mothers see more

negative
behaviors in other
children

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4 Stages
Sensory Motor
0 to 2 years

Period of Formal
Operations
11 to adult

Preoperational
2 to 7 years

Period of Concrete
Operations
7 to 11 years

Sensorimotor Period (0-2)

Child Infant
Objects in environment = permanent
Difficult communication (language
capabilities)
Little ability to interpret sensory data
Can think of time only in
the present

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Preoperational Period (2-7)

Use words to symbolize objects
Egocentric
Limited logical reasoning (dominated
by immediate sensory impression)
Animism inaminate objects
have life

Period of Concrete Operations

(7-11)
Improved reasoning
Can see other points of view
Ability to reason tied to concrete
objects
Limited abstract thinking

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Period of Formal Operations

(11-adult)
Intellectually treat like an adult
Have abstract reasoning & concepts
Do NOT talk down to a child

Lets Review
Each Age!

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Ages
2 Ages
CHRONOLOGICAL AGE
MENTAL AGE
ADDRESS the childs MENTAL
AGE

2 Year Olds

terrible twos
Varied vocabulary
Solitary play, SHY
AFRAID of NOISE, sudden
movements
React better to showing rather
than telling
Does not want to be separated
from parent

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2.5 Year Olds

Suggestible
Usually instinctive
May generalize (may see
white coat, and feel like at
the pediatrician)
Not interested in
interpersonal relationships

3-3.5 Year Olds

Better communication
Will develop interpersonal
relationships
Imaginative
Follows directions
Uncertain/insecure
Will often sepearate from
parent

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4-4.5 yo

why?, Asks lots of questions

Defiant age, independence & resistance
Responds well to verbal direction
Likes talking
React emotionally to insults, susceptible to
praise
Willing helpers
Usually cooperative if happy home life

5 yo

Well adjusted, matter of fact

FACTUAL (no fantasy)
Desires to act older & more compliant
** Must be truthful, maintain childs trust
Aware/proud of possessions
Responds to PRAISE

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5.5-6 yo
School age
Moves away from close family
dependency
Anxiety (new situations)
changed child
Prone to temper tantrums
May be afraid of animals, people,
darkness, bodily harm

6 yo
Anxieties diminish, behavior improves
Well adjusted, happy
Usually reacts favorably

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7 yo

Better control
Somewhat withdrawn, moody, sulky
Anxious to please, CONSIDERATE
GIVE PRAISE
More verbal
Deep, worrisome fears (about acceptance)
Dont like to be touched
Fantasy, super-imaginative

8 yo

Dramatic, tall tales

Critical of themselves/others, sensitive
Verbal aggression
Fewer fears
More adaptable
Interested in relationships
Desires to be treated as an adult
NEVER DEMEAN

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9 yo
More responsible, independent,
cooperative
Likes compliments, competitino
Self-critical, uncertain
Extreme emotional states
Fewer fears
Upset by own mistakes
Expected to be on own more

10 yo
Wonderful
Easy going, well-balanced
Infrequent anger (violent, but quickly
resolved)
Wants adult relationships
Matter of fact

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11 yo
BEHAVIOR PROBLEM- most
worried/fearful age
Health worries
FEARS: unknown, animals, INJECTIONS
Genuinely afraid of dental procedure
Sensitive
Proud, selfish, competitive,
belligerent, jealous, resentful
Detailed conversation

12 yo

Well adjusted, happy

Want to be treated as an adult
Likes HUMOR
Preoccupied w/ food & eating
Usually not a problem in the dental office

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13 yo sad
14 yo outward, well adjusted
15 yo dislike authority, may blame
dentist
16 yo happy, well adjusted

BEHAVIOR MANAGEMENT
A continuum of interaction
Purposes:
Establish rapport
Promote + behavior
Facilitate effective, efficient, safe treatment

Base decisions off risk vs benefit

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Review of Behavior
Management Terms
behavior: observable act that can be described
or measured reliably
Classical conditioning: conditioned reflexes
established by association of one stimulus w/
another stimulus thats known to cause
unconditioned reflex
Behavior modification: shaping
behavior

Behavior Modification
Stimulus-response
Motivation
+ reinforcement: right response produces a
goal/reward response reinforced
- reinforcement: response takes away an
unpleasant stituation
Generalization: may react to new
situation as if an old, similar situation
Discrimination: opposite of
generalization

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Behavior Mod . . . Cont.

Extinction: response not reinforced, then
response decreases until eliminated
Adverse conditioning: punishment
Desensitization: present milder component of
stimulus until no longer produces anxiety
Modeling: imitation
Successive approximations: reinforce behaviors
that more & more
closely resemble the final desired
response

GOALS
Quality treatment
Trust, reduce fear
Positive attitude
Reinforce positive behavior
Extinguish inappropriate behavior

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Behavioral Evaluation

Parental
interview
(Parent-Dentist)
Developmental
milestones
Social and health
history
Attitudes and
Expectations

Indirect
observation of
Child-Parent
interaction by
Dentist
Attachment
and
temperament

Direct child
interaction
(Child-Dentist)

Behavior Eval
Child Temperament/Attachment
TEMPERAMENT
Childs interaction with the environment
Childs initial response to new situations
Easy, difficult, slow to warm up, mix

ATTACHMENT
Childs intensity of interaction with
caregiver
High intensity indicates emotional
immaturity and insecurity

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11/3/2014

TEMPERAMENT

Easy:

Difficult:

Irregularity of biologic functions

Withdrawal response with new
stimuli
Very slow in adapting
High frequency of negative moods
Frequent intense negative reaction

Highly regular in biologic functions

Positive approach to new stimuli
Rapidly adaptable
Frequent positive moods
Low or mildly intense reactions

Attachment: emotional bond felt by

humans to special people in their lives

Occurs in latter
part of first year
of life

Central part of
cognitive and
social
development

Once secure
base formed ,
child is
confident in
exploring the
environment

Lack of
attachment
may confer
some risks of
behavior
difficulties later
in life

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FEAR
Greatest management problem
= primary emotion, feeling of impending danger,
cognitive development link

Types of Fear
Objective Fears responses to stimuli that are
felt, seen, heard, smelled, or tasted that are of a
disagreeable or unpleasant nature
Subjective Fears based on feelings or
attitudes that have been SUGGESTED
Imitative fears subtle transmission, parent
displays and child acquired without
being aware of it

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Common Fears

Age 3-4
Age 1-2
Large
movements
Loud sounds
Strangers
Separation

Animals
Being alone
Imaginary
creatures
Physical harm
Dark

Age 6-8
Age 5
Decrease in
fears

School failure
Ridicule
Death of loved
one

DENTAL FEAR
History of non-invasive = less fear
Coping skills increase with history of noninvasive appointments
Childs perception of appointment is decisive in
developing fear- over preparation
Dentist empathy childs perception of dentist
Parental fear
Childs temperament
Age & gender

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Anxiety
= apprehension,tension, or uneasiness which
stems from the ANTICIPATION of danger, the
source of which is largely unknown or
unrecognized, intra-psychic
Often indistinguishable from fear

BEHAVIOR TYPES

Cooperative
Lacking cooperative ability
Potentially cooperative = pre-cooperative
Uncontrolled behavior
Defiant behavior
Tense-cooperative behavior
Whining behavior
The fearful child
The timid/shy/bashful child

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11/3/2014

Types of Crying

Obstinate
Crying

Frightened
Crying

Hurt Crying

Compensatory
Crying

Reasons for Adverse Behavior

Lacks
comprehension
- Dental
procedures,
personnel, office
env

Fear

Immature or
impaired
development

Impairments
- Stability & m
control
- Impulse
control

Safety =
paramount
- For patient &
dental team

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Behavior Management
Begins at 1st Contact
Initial
Contact &
Appoinment
Scheduling

Pre-Visit
Letter if
Desired

Dental
Environment
- Office
design &
decor

Treatment
Around
Other
Children

Pre-Visit Letter
Includes:
Appointment confirmation/time
Express appreciation
Details of first visit
Specific information fees, policies

Advantages:
Education
Parent understands how to prepare
child
Parent understands visit is
DIAGNOSTIC

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11/3/2014

Dental Environment
Childrens corner in reception area
toys, puppets, books, games
Operatory adult chair OK to treat
children, sound control?

Consultation
rooms

Preventive
orientation sink
& mirror at
childs height

Bright, attractive
colorful walls,
pictures

INFORMED CONSENT
Legal standard requires that the
consenter be:
informed
competent
acting voluntarily

Doctorpatient relationship is:

fiduciary
not dominate/subordinate

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Prognosis of
Procedure
- good
- fair
-poor

Possible need for

unforeseen treatment,
or change of treatment
as planned
INFORMED
CONSENT
ELEMENTS

Prognosis if procedure
not undertaken

Alternatives to
proposed procedure
- sedation (may still
require immobilization)
- treatment under GA

Basic Behavior
Guidance
TSD

Non-verbal

Voice
Control

Positive
Reinforce

Parental
Presence
Absence

Distraction

Nitrous
Oxide

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Non-invasive Management
Techniques
Communication-based techniques

Do not require separate informed

consent

Designed for
helping child cope with anxiety
contingency management
behavior shaping

TELL-SHOW-DO
Tell: Explain what going to do (before, during,
while)
Truthful
Use words child understands, dont talk down to
Be cautious with fear-promoting words
Bother instead of hurt
pinch instead of stick

Show: show what to expect

Anesthesia: pinch hand as demo
Avoid fear promoting instruments

Do: do it, use same voice

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This is how I count my fingers.

Lets count your

fingers!

Lets count some teeth!.

DENTAL TERM

WORD SUBSTITUTE

Air

Mr. Wind

Water

Water-gun
Mr. Whistle sings to you

Dental
term

substitute

High speed handpiece

Low speed handpiece

Mr. Bumpy

SSC

Tooth hat

Anesthetic

Sleepy juice

SS band

Tooth ring

Burr

Brush/pencil

X-ray head

Camera

Caries

Sugar bugs, brown spot, sick tooth

Explorer

Tooth counter

X-ray

picture

Evacuator

Vacuum cleaner, straw

Impression material

Pudding, mashed potatoes

Matrix

Filling fence, ring

Prophy paste

Special toothpaste

Fluoride

Vitamins

Rubber dam

Raincoat

Rubber dam clamp

Tooth button/ring

Rubber dam frame

Coat rack

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Distraction
Verbal distractions
Walkman-type
headphones, handheld
games
Ceiling-mounted posters
TV

Distracters must be
intense to compete
with patients desire to
escape

Distracters

VOICE CONTROL
Appropriate child
adult roles

Alteration of
body, tone, or voice

Facial
expression
must mirror
tone.

Sudden, firm
commands.

HEY . . . STOP THAT.

THATS NOT ALLOWED
HERE

Gain attention,
compliance

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11/3/2014

Voice Control
Rated as unacceptable by
parents (takes authority
from parent)

Make sure negative

behavior is not related to
actual pain

Praise desired behavior

Perceived as aggressive

Alternate method lower

tone, cooperation as
choice, and disruptive
behavior will require a
start over

Parental Presence
Wide diversity in practitioner philosophy and
parental attitudes regarding presence or
absence
Parenting styles coping skills and selfdiscipline required to deal with new
experiences
Communication can be hampered
Range great benefit / disaster
Always with Special Needs Child
Parent must be part of solution and not part of
problem

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11/3/2014

INFORMED
CONSENT a
MUST before the
Following
Behavior
Management
Techniques!

Stabilization
Protective stabilization = immobilization = restraint
= support
Good for patient and personnel safety when
absolutely necessary
Use least restrictive necessary
ACTIVE STABILIZATION
Caregiver/assistant/dentist performs
Ex: holding arms, legs, head

PASSIVE STABILIZATION
Ex. Pediwrap, papoose board

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11/3/2014

Passive Stabilization

Active Stabilization

Hand Over Mouth / Flooding

Used to re-establish communication when a
child has become hysterical/defiant
** child must be of normal intelligence
HAND OVER MOUTH tell child must stop
screaming in order to remove hand
NEVER use with frightened children, NEVER
do if angry

DONT DO
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Nitrous Oxide Sedation

Contraindications:
URI
Psychotic hx
* Low
solubility in
blood
* Excreted
unchanged
in the lungs,
and readily
diffuses into
alveolar
membranes

Correct total
liter flow is
determined
by the
amount
necessary to
keep
reservoir bag
1/3 to 2/3 full.

Side effects:
diffusion hypoxia
nausea

Conscious Sedation
Premedication
oral, nasal,
parenteral
routes

Special permits
required,
certification,
training. Need
experience

Must have
special
equipment,
monitor for
emergencies
*PULSE OX

Know:
- Age
- Weight (use weight
that is the least b/t
dosing and ideal
weight)
- Mental attitude
- Drug
properties/dosing

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General Anesthesia

General Anesthesia- Indications

Weigh Risks vs. Benefits
adequate
cooperation
cant be achieved
by usual behavior
management
techniques,
predmedications,
or acceptable
physical
restraint
Multiple
quadrants that
will require multiple
appointments
in the young
child

mental
disabilities to
degree that dentist
cannot
communicate.

Systemic
disturbances
and congenital
anomalies that
dictate general
anesthesia

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Deferred Treatment
ART

Preventive
program

Risk/benefit

Review of Dos
and Donts

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Dos
Be prepared (children have small attention span), start on
time
Be relaxed
Introduce yourself & get to know child
Give child lots of attention
Explain everything
Compare to children in + ways
PRAISE (not flatter)
Allow to use restroom before and drink of water if ask
Make everything pleasant
Avoid getting mad
Keep communicating
Set limits
Establish signals (to convey feelings/concerns)
Enjoy yourself

Donts

Lie
Make fun of the child
Scold/ridicule
Compare to other children in a negative way
Be too loud/forceful/overbearing
Use baby talk or talk down
Dont ignore
Use words that incite fear (needle, cut, drill, sharp, stick,
blood, sting, shot, bur, bite, pull, break)
Carry without parents permission
Be over-sympathetic
Ask questions where child can say no
Allow child to see scary instruments

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11/3/2014

Some Key Law Terms to

Know and AVOID
Assault = An intentional display of force that would give
the victim reason to fear or expect bodily harm; which
may be committed without touching or bodily harm

Battery = Unlawful application

of force to the body of another;
unprivileged touching of
another persons body

MEDICAL BATTERY
- no need to prove injury or negligence
- Necessary to prove that the medical personnel engaged in
unauthorized touching, contact or handling of the victim
- Ex. Perform treatment without informed consent

MEDICAL MALPRACTICE
- negligent acts performed by medical personnel

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QUESTIONS??

Works Cited:
Rockman, Roy A. Child Taming: How to Manage Children in Dental Practice
Furnish, Guy. University of Louisville School of Dentistry Pediatric Manual

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