behaviour Modification Techniques

Dr.M.Ganesh,MDS(Pediatric Dentistry)BEHAVIOUR MODIFICATION TECHNIQUES

Dr.M.Ganesh,MDS(Pediatric Dentistry)

Dr.M.Ganesh,MDS(Pediatric Dentistry)Behavior modification techniques:-Introduction - Definition - Classification of behavior management modalities Behavior management techniques:- - Desensitization Introduction - Definition - Indications - Technique - Tell, Show, Do - Verbal communication - Conclusion - Modeling Introduction - Requirements - Technique - Contingency management Definition - Reinforcers - Types of reinforcersKey points.Conclusion.References.


Dr.M.Ganesh,MDS(Pediatric Dentistry)BEHAVIOR MODIFICATION:- The attempt to alter human behavior and emotion in a beneficial way and in accordance with the laws of learning.BEHAVIOR SHAPING:- The procedure which slowly develops behavior by reinforcing a successive approximation of the desired behavior until the desired behavior comes into being.BEHAVIOR MANAGEMENT:- The means by which the dental health team effectively and efficiently performs dental treatment and thereby instills a positive dental attitude.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Behavior management modalities:-Non pharmacological (psychological approach)Pharmacological


Dr.M.Ganesh,MDS(Pediatric Dentistry)Non-pharmacological methods of behavior management:-CommunicationBehavior modification (shaping) a) Desensitization b) Modeling c) Contingency managementBehavior management a) Audio analgesia b) Biofeedback c) Voice control d) Hypnosis e) Coping f) Humor g) Relaxation h) Aversive conditioning


Dr.M.Ganesh,MDS(Pediatric Dentistry)Pharmacological methods of behavior management:-1. Pre-medication a) Sedatives and hypnotics b) Anti-anxiety drugs c) Antihistamines2. Conscious sedation3. General anesthesia


Dr.M.Ganesh,MDS(Pediatric Dentistry)SYSTEMIC DESENSITISATION


Dr.M.Ganesh,MDS(Pediatric Dentistry)SYSTEMIC DESENSITISATIONIntroduced by Joseph Wolpe.Reciprocal InhibitionProcess by which a person experiencing anxiety in association with a certain stimulus is made to experience a response that inhibits anxiety to that same stimulus.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Behavior therapists have found that systemic desensitization is one of the most effective methods for reducing maladaptive anxiety.The technique has been found not only useful in dental situations, but also in the treatment of other phobias such as the fear of heights, crowded places and isolation.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Systemic desensitization is effective because the patient learns to substitute an appropriate, adaptive , emotional response Relaxation for an inappropriate maladaptive, response anxiety. This Technique is used to remove fears and tensions in children who have had previous unpleasant dental experiences or negative behavior.


Dr.M.Ganesh,MDS(Pediatric Dentistry)The Technique:-1) Training the patient to relax2) Constructing a hierarchy of fear producing stimuli related to the patients principal fear.3) Introducing each stimuli in the hierarchy in turn to the relaxed patient, starting with the stimulus that causes least fear and progressing to the next only when the patient no longer fears that stimulus.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Technique in its classical form:-Teach the patient how to relax; to induce a state of deep muscle relaxation.Introduce imaginary scenes related to his fears, presented in a graduated fashion so that the scenes only provoking minimal anxiety are described.Gradually more stressful situations are presented.Anxiety is minimized through the use of relaxation.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Basis of the childs fear:-Childs fear General fear ( Fear of the dental environment) -- Specific fear ( Fear of the drill or the needle)When this information is known, a hierarchy of fear producing stimuli can be constructed.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Fear of the dental environment in general:-Desensitization include successive introduction of the child to the following stimuli:-Reception and waiting roomDentist and nurseDental chairOral examinationprophylaxis


Dr.M.Ganesh,MDS(Pediatric Dentistry)Fear of the drill and of the needle:-Selected stimuli may be:-Brushing the childs teeth with a prophylaxis brush held in hand.Brushing with a prophylaxis brush in slow speed hand piece.Using a fine finishing bur in a slow speed hand piece revolving in the mouth but not in contact with teeth.Applying the finishing bur gently to a tooth surface.Desensitization from the needle fear is more difficult, especially with young children, who cannot be expected to react favorably to the sight of a needle, even less ,to its introduction into their mouth.Some dentist prefer to show the patient the cotton roll with topical anesthetic and avoid sight of the needle, while others consider some for of sedation.


Dr.M.Ganesh,MDS(Pediatric Dentistry)TELL, SHOW, DO TECHNIQUE (TSD)Concept of TSD was introduced by Addleson (1959)Most common method of behavior shaping used by many professionals who work with children.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Indications of the technique:- During a childs initial dental visit.Subsequent appointments when new procedures are being carried out.Fearful child.Patients not familiarized with certain dental techniques.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Components of this technique:-TELL:- Telling the child about the new situation and what is going to be done.SHOW:- Showing the child the new environment; Demonstration for the patient of the visual, auditory and tactile aspect of the procedure.DO:- Doing what the child was told would be done.


Dr.M.Ganesh,MDS(Pediatric Dentistry)VERBAL COMMUNICATIONCommunication should be comfortable and relaxed.Language which is preferred by the child, containing words that express pleasantness, friendship and concern.Voice that is used should be constant and gentle. Tone of voice can express empathy and firmness.Patient prefers being addressed by his name.Use of euphemisms.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Euphemistic Language The term "euphemism", derived from the Greek EW (well) and Phanai (to speak), originally meant "to use words of good omen." , the use of euphemisms is particularly indicated in place of:a) fear-provoking or threatening words, and b) technical termsThe use of threatening and technical language is a frequent barrier to communication between dentist and patients. It either creates apprehension and confusion or intensifies them if already existent. In order to prevent potential problems that can result from the use of emotionally-charged language


Dr.M.Ganesh,MDS(Pediatric Dentistry)Dental Nomenclature Euphemisms :-Amalgam - silver filling Anesthesia - sleepy water Bur - germ chaser Dental caries - tooth bugsDental explorer - tooth counter Topical fluoride - tooth vitamins Matrix band - Queen's crownProphylaxis paste - toothpaste Radiograph - tooth picture Rubber dam - raincoat Stainless steel crown - shiny cap X-ray - machine camera


Dr.M.Ganesh,MDS(Pediatric Dentistry) For whatever treatment TSD is being employed, it is important to ensure a smooth continuity through the T-S-D stages.The explanations should not be detailed or protracted, as this would tend to confuse the child and perhaps arouse anxiety; they should be given simply and casually.Similarly the demonstration should be given briefly so that the actual treatment follows without undue delay.A positive reinforcement should be given immediately to a child who follows TSD successfully.


Dr.M.Ganesh,MDS(Pediatric Dentistry)MODELLING


Dr.M.Ganesh,MDS(Pediatric Dentistry)MODELLINGIntroduced my Bandura in 1969.He stated that learning occurs only as a result of direct experience which can be vicarious- witnessing the behavior and the outcome of that behavior for other people.He found earlier that children exposed to an aggressive model will imitate that type of behavior both verbally and nonverbally.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Types of models:- Live models ( siblings, parents, etc).Posters.Filmed models.Audiovisual aids.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Modeling technique requirements:-Concentrated attention must be expended toward the witnessing of the model. Brief exposure to the modeling procedure is not productive.There must be sufficient retention of the desirable behavior in the absence of a model.Physical guidance of the desired behavior may be necessary.One must be able to reproduce effectively the behavior modeled.The newly acquired behavior must be appropriately rewarded to retain it.


Dr.M.Ganesh,MDS(Pediatric Dentistry)The basic modeling procedure involves allowing a patient to observe one or more individuals (models) who demonstrate appropriate behavior in a particular situation.The patient will frequently imitate the models behavior when placed in a similar situation.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Modeling made more effective:-When the observer is in a state of arousal,When the model has relatively more prestige or status, andWhen there are positive consequences associated with the models behaviour.


Dr.M.Ganesh,MDS(Pediatric Dentistry) Modeling serves 4 basic functions:-Stimulation of a new behavior.Facilitation of behaviors already in the patient in a more appropriate manner or time.Disinhibition of behaviors avoided because of fear.Extinction of fears.


Dr.M.Ganesh,MDS(Pediatric Dentistry)CONTINGENCY MANAGEMENTThe presentation or withdrawal of reinforcers is termed contingency managementBehavior therapists define dispensing a reinforcer contingently as giving a reinforcer after a desired behavior has been performed. (Do not confuse Contingent:- dependant on chance)


Dr.M.Ganesh,MDS(Pediatric Dentistry)Reinforcer:-By definition, reinforcers always increase the frequency of a behaviorReinforcement is the strengthening of a pattern of behavior, increasing the probability of that behavior being displayed again in the future. Two types of reinforcers:- a) Positive b) NegativeA positive reinforcer is one whose contingent presentation increases the frequency of a certain behavior.A negative reinforcer is one whose contingent withdrawal increases the frequency of a desired behavior


Dr.M.Ganesh,MDS(Pediatric Dentistry)Reinforcers also classified as:-


Dr.M.Ganesh,MDS(Pediatric Dentistry)Material Reinforcers:-They are perhaps the most effective for children.Suitable items would be balloons, coloring sheets, stickers, toothbrushes, games, etc. ( Try and keep the item of dental significance)Candy, sweets, chocolates, etc, are contraindicated as they are baneful to oral health.A present should be given at the end of a session as a sign of approval of good behavior.Items should not be offered as a bribe in hope of encouraging good behavior, and certainly not be given if the child has not been cooperative.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Social reinforcers:-Social reinforcers probably represent the majority of all reinforcing events affecting human behavior.Praise, positive facial expressions, nearness, and physical contact are effective reinforcers because people have learned to value other people.For best effect, positive reinforcement , like praise, needs to be given throughout the session immediately after appropriate behavior is demonstrated. Praise at the end alone does not seem to work: you must make it clear to the child which behavior is being rewarded.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Common social reinforcers:-Praise:GoodThats rightExcellentExactlyGood jobGreatThank you2) Facial expressions:SmilingWinkingLaughing3) Physical contact:Patting head, shoulder, or back.Shaking/ holding handHugging


Dr.M.Ganesh,MDS(Pediatric Dentistry)Activity Reinforcers:-Activity reinforcers involve the opportunity or privilege of participating in a preferred activity after performance of a preferred behavior.First you work , then you may play principle.Activity Reinforcers:Seeing a movie.Having a friend stay overnight.Having a party.Going shopping.Going out to play.Playing games with friends.Staying up late.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Little application of activity reinforcers in the dental office, but they may be used with significant success in the home for programs such as habits or plaque control if the parents can be trained to observe and reinforce appropriate behavior.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Some application of activity reinforcement in the dental operatory can be used, and this is due to childrens inherent curiosity.Following appropriate behaviors children maybe allowed to observe treatment in a hand mirror, or participate in procedures by holding instruments (not anything sharp).


Dr.M.Ganesh,MDS(Pediatric Dentistry)Key Points:-Aim of behavior management is to instill a lifelong, positive attitude to dental health.Facial expression, touch, body language and voice tone are all critical elements of child management.tell, show, do can be used for all patients, but remember to make language appropriate for each child.Let the patients know you care. Talk to them. Ask if they are all right.Remember to smile. It shows in your eyes and can be heard in your voice.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Conclusion:-Desensitization, Modeling and Contingency management techniques have been found useful in the dental office.Application of these techniques , separately or in combination, will frequently enable the dentist to elicit successively more appropriate behaviors.


Dr.M.Ganesh,MDS(Pediatric Dentistry)References:-Child taming Barbara Chadwick & Hosary.Management of dental behavior in children Ripa & Barenier.Manual of Pediatric dentistry Churchhill & Livingstone.Dentistry for children and adult - McDonald & Avery.Textbook of Pedodontics Shoba Tandon.Child dental health Holloway.Journal of Pediatric dentistry vol.22 (2000)


Dr.M.Ganesh,MDS(Pediatric Dentistry)THANK YOU.


Dr.M.Ganesh,MDS(Pediatric Dentistry)Dr.M.Ganesh,MDS(Pediatric Dentistry)Ahmedabad Dental College*Ahmedabad Dental College

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behaviour Modification Techniques