1. BEHAVIOR MANAGEMENT
By
Dr Nidhi Ravindran

2. CONTENTS
• INTRODUCTION
• DEFINITION
• CLASSIFICATION
• PHARMACOLOGICAL
• NON PHARMACOLOGICAL
1. Communication
2. Behaviour shaping (modification)
i. Desensitization
ii. Modeling
iii. Contingency management
3. Behaviour management
i. Audio analgesia
ii. Biofeed back
iii. Voice control
iv. Hypnosis
v. Humor
vi. Coping
vii. Relaxation
viii. Implosion therapy
ix. Aversive conditioning
• BEHAVIOR MANAGEMENT OF CHILDREN WITH HANDICAPPING CONDITIONS
• CONCLUSION

3. INTRODUCTION
The key to successful orthodontic treatment
is a cooperative patient. To achieve this
prerequisite it is of utmost importance to
discover the actions that will produce the most
positive response from the patient. To determine
a child’s behavior in dental office and the factors
influencing it we must study a child’s mental and
emotional make up that constitute the
“psychology” of that child.

4. DEFINITIONS
PSYCHOLOGY is a branch of science which deals with
mind & mental processes in relation to human &
animal behaviour.
BEHAVIOR MANAGEMENT is defined as the means by
which the dental health team effectively and efficiently
performs dental treatment and thereby instills a
positive dental attitude (Wright 1975)
BEHAVIOR MODIFICATION: defined as the attempt to
alter human behavior and emotion in a beneficial way
and in accordance with the laws of learning.

5. Communication
Types:
Verbal Communication- Speech
Non verbal / Multisensory Communication
Body language
Smiling
Eye contact
Showing concern
Touching
Patting
Hugging
Both using nonverbal and verbal

6. Desensitization
It is accomplished by teaching the child a completing response
such as relaxation and then introducing progressively more
threatening stimuli.
Method popularly used nowadays – Tell shows Do (TSD)
technique (Addleslon 1959). Tell and show every step and
instrument and explain what is going to be done.
Continuously and in grades from the least fear promoting
object or procedure and move in higher grades to more
fearful objects.By having verbal (tell) and nonverbal (show
and do) interactions, available, one can overcome many
small dental related anxieties of any child.

7. Modeling
Introduced by (Bandura 1969) developed from social
learning principle procedure involves allowing a patient
to observe one or more individuals (models) who
demonstrate a positive behavior in a particular
situation.
Modeling can be done by:
Live models – siblings, parents of a child
Filmed models
Posters
Audiovisual aids

8. Contingency Management
It is a method of modifying behavior of children by
presentation or withdrawal of reinforcers.
These reinforcers can be: -
Positive reinforcer- whose contingent presentation
increases the frequency of behavior. (Henry W Fields
1984)
Negative reinforcer – whose contingent withdrawal
increases the frequency of behavior. (Stokes and
Kennedy 1980)

9. Behavior management
Audio analgesia: or “white noise” is a method of reducing Pain (pleasant
music)
This technique consists of providing a sound stimulus of such intensity that
the patient finds it difficult to attend to anything else. (Gardner Licklider
1959)
b) Biofeedback:
It involves the use of certain instruments to detect certain physiological
processes associated with fear (Buonomono 1979). Eg: -
electromyography.
C) Humor:
It helps to elevate the mood of the child, which helps the child to relax.
Functions of humor are – social, emotional, informative, Motivational,
cognitive.

10. Coping:
It is the mechanism by which a child copes up with the dental
treatment. It is defined as the cognitive and behavioral efforts
made by an individual to master, tolerate or reduce stressful
situations. (Lazaue 1980).
Signal system:
In this method as a part of coping, when it hurts, we ask the child to
raise his hand as suggested by Musslemann 1991.
e) Voice control:
It is the modification of intensity and pitch of one’s own voice in an
attempt to dominate the interaction between the dentist and the
child.

11. Aversive Conditioning
It can be a safe and effective way of managing
an extremely negative behavior. Those
dentists who contemplate using it should
obtain parental consent prior to its use
(Patricia P Hagan 1984).
Two Common Methods used are
• Home
• Physical restrains

12. Hand over mouth exercise (HOME)
The behavior modification method of aversive conditioning is also known as HOME.
Introduced by Evangeline Jordan 1920.
The purpose is to gain attention of the child so that communication can be
established.
Indications
A healthy child who can understand but who exhibits defiance and hysterical behavior
during treatment.
3-6 year old children.
A child who can understand simple verbal commands.
Children displaying uncontrollable behavior.
Contraindications
Child under 3 years of age.
Handicapped /immature/frightened child.
Physical, mental, and emotional handicap.

13. PHYSICAL RESTRAINTS
Restraints are usually needed for children who are
hypermotive, stubborn or defiant (Kelly 1976).
It involves restriction of movement of the child’s head,
hands, feet or body.
It is the last resort for handling uncooperative patients or
handicapped patients
It can be
Active – restraints performed by the dentist, staff
or parent without the aid of a restraining device.
Passive – with the aid of restraining device

14. TYPES OF RESTRAINTS
A) For body
Pedi wrap
Papoose board
Sheets
Beanbag with straps
Towel and tapes
For extremities
Velcro straps
Posey straps
Towel and tape
For the head
Head positioner
Forearm body support
Mouth
Mouth blocks
Banded tongue blades
Mouth props

15. PHARMACOLOGICAL METHOD OF
BEHAVIOUR MANAGEMENT
PRE-MEDICATION
• Sedatives and hypnotics
• Anti-anxiety drugs
• Antihistamines
• Conscious sedation
• General anesthesia

16. BEHAVIOR MANAGEMENT OF CHILDREN WITH HANDICAPPING
CONDITIONS
Mental Retardation
It affects 3% of the population, is the most common of the handicapping conditions. It may occur solely
as an intellectual deficiency, it may be one of a combination of disabilities, or it may be one
manifestation of a syndrome (Down’s syndrome).
By definition those who are mentally retarded have a tested intelligence quotient (IQ) of 69 and below.
It is vitally important for the dentist to accept the patient first as an individual and secondly as a patient
with a handicap (Album 1962) the practitioner should attempt to discover from the parents and
others as much as possible about the child. Parents should be asked how they mange the child.
For patients on the lower curve of the IQ scale the dental chair is positioned before the patient is
seated. These patients become easily alarmed when the dental chair is moved.
Since many mentally retarded children have short attention spans, the unmediated child usually does
not tolerate lengthy appointments well. Constant patter, television, or audiovisual instruction
programs can serve as distracters during treatment procedures.
Adapted behavior modification can be used with many mentally retarded children. (Eg: - body language
with the child deficient in verbal skills).
Because mentally deficient children may fail to comprehend they are prone to postoperative soft tissue
biting. Ultra short acting local anesthetics should be used. Nitrous oxide sedation benefits some of
these patients if they accept the mask.
Major sedation and restraints may be required for some mentally retarded children.

17. Convulsive Disorders.
Paroxysmal attacks of unconsciousness or impaired consciousness may occur, usually with a succession
of tonic or clonic muscular spasms.
The dentist should ask a parent if the child’s seizures are under control and if not, how frequently they
occur, when the last seizure occurred and how the parent manages the seizures.
The dentist should contact the child’s physician if the child is taking seizure-control medication.
Sometimes an increase in medication dose before a dental visit prevents seizure occurrence.
Care should be taken to avoid inducing seizures. (Hall 1982) suggests that anxiety, intense light and
intravascular local anesthesia are seizure triggers. Hall recommends sunglasses to reduce the glare
from the operatory light and an aspirating syringe to avoid injection into blood vessels.
A mouth prop consisting of tongue blades wrapped in gauze and heavily taped should be available when
treating epileptic children.
In the event of a seizure all instruments should be removed from the mouth immediately. A rubber dam
can be used with epileptic children.
A restraining device can also be an asset when treating such patients.
Epileptic children should never be left in the operatory unattended.

18. Cerebral Palsy
The incidence of neuromotor disorders ranges from one to five per 1000 live births (1971). Cerebrak
palsy one of the most common of these conditions, is a CNS disorder manifested by impaired motor
function.
While many children with cerebral palsy can walk into the operatory, others are unable to do so. (Parent
assistance should be sought).
The dental chair should be preset in the approximate position desired by the operator before the
patient is seated.
While examining new patients, the dentist should evaluate their muscle movements carefully. It may be
desirable to passively hold a mouth prop, consisting of taped tongue blades, in the oral cavity if
there is concern about the patient involuntarily closing the mouth.
Noise making instrument should be avoided if possible as it increases the involuntary contractions of
the athetoid patient.
Since these patients have poor control of their orofacial musculature, post operative soft tissue biting
can be a problem. Therefore whenever possible the dentist should use ultra short acting
anesthetics. Nitrous oxide sedation may help control movements.

19. Progressive Neuromuscular Disability
Eg: - myotonic dystrophy, muscular dystrophy.
Since these patients may have postural problems. A strap
to hold child on the dental chair is frequently
appreciated.
To provide realistic treatment plans for these patients,
the dentist has to know the prognosis of a child’s
condition.
Since dental health is of secondary importance for many
of these children, the dental hath team has to be
extremely patient and

20. Deafness
Children with hearing handicaps communicate visually through lip reading. In some instances parents
will be required to transmit long complex messages.
Tell show do TSD technique with the following changes is effective with the hearing handicapped :-
Remaining in the child’s view to maximize visual communication.
Speaking with good lip action to convey information from a distance of about 3 feet.
Substituting verbal reinforcement with smiles, squeezing the arm gently etc., to convey the dental
team’s appreciation of a child’s cooperation.
Using the tactile sense.
Because the deaf children can be very impatient with delays, an organized plan of procedure is of
paramount importance.
For older children “magic slate”, a small chalkboard should be available to enhance communication.
The hand mirror is an invaluable aid during most procedures, allowing communication through the
child’s available senses.

21. Blindness
Non sighted or the partially sighted children must
be introduced to foreign environments very
slowly.
Constant voice contact should be maintained with
the blind children.
The “show” portion of behavior shaping is greatly
limited or impossible with blind children. Some of
the modification are-increased use of auditory,
tactile olfactory and taste senses.

22. Autism
This condition which manifests itself early in childhood is characterized by certain
behavioral traits. These children are unresponsive and uncommunicative, take a
greater interest in inanimate objects than in people. Most do not use language
properly, and many do not speak at all.
The autistic child usually creates a difficult management problem from the beginning.
Repeated visits to the dental office for oral hygiene instruction before examination
procedures desensitize autistic children.
A quiet, modulated voice can have a calming effect. Some of them also appear to
accept positive reinforcement such as smile or a pat on shoulder.
The autistic child is distracted easily. Therefore only minimal movements should be
made during treatment.
Some become calm and highly cooperative with the use of a body restraint, which
protects the patient and the dentist.
Since most autistic children do not have medical complications, sedation can be used
with minimum risk.

23. CONCLUSION
A sound knowledge in child psychology and behavior management is essential
for a successful practice. Psychology and behavioral sciences have been an
integral part of orthodontics both in research and in clinical practice since
the early days of this century.
Throughout the course of orthodontic treatment, the orthodontist should
keep in mind the fact the psychological outcome of treatment are as
important as the occlusal and functional outcomes. Producing an excellent
finished result is the primary responsibility of an orthodontist, but
producing happy, self-assured patient is an added opportunity. While
undergoing orthodontic treatment, the child is expected to follow
instruction daily – to wear elastics, head gear, maintain ideal oral hygiene,
endure discomfort, keep regular appointments and refrain from eating
many foods that can be detrimental to the appliances. Therefore
successful child management can only ensure the child to be co-operative,
which in turn results in a complete and desired optimal treatment result.