Pedo clinical notes

1. Frankel Behaviour Scaling Grade

2. Behavioural management

Age General developmental milestones and child behaviour Dental implications

Age 3–4 • In their first 3–4 months, babies become extremely interested in their
months world of people, places and objects.

Age 6–8 By 6–8 months, infants are discovering new ways to share and express
months their curiosity, joy, frustration and fear within their world. Babies can
shift their attention while keeping in mind the object on which they
were focusing. They can look at a ‘teddy bear’ and be delighted by it,
then turn to look at the parents to share those feelings.
Advice regarding tooth eruption, initial oral hygiene measures
and teething.
It is generally accepted that teething has the potential to cause local
irritation, however, there is no accepted evidence connecting the
systemic symptoms, such as diarrhoea, flushed cheeks and fever, to
 By 8 months, babies are beginning to crawl and discover their
surroundings, learning to distinguish differences in their world and
people.
Mobility sets the stage for the first significant appearance of fear.
Stranger awareness begins at this time.
Understanding of spoken words and non-verbal communication
(receptive language) develops at a much greater rate than expressive
language.
The infant learns to ‘social reference’, where he/she shows interest in
an object or person and then turns to the parents for emotional
feedback. The infant is able to read the parent’s/caregiver’s facial
expression, tone of voice and words, to under- stand the concept of a
particular danger or safety.
Age 9–12  By 9 months, two-way conversations about feelings are now
months possible. Infants become aware of the possibility of others sharing
their thoughts and feelings. Understanding and labelling the
infant’s feelings and experiences can help with relationship
building, acceptance and trust.
 Object constancy or permanence is developing in which infants
begin to realize that objects and people still exist even when out of
sight (e.g. repeatedly throwing the spoon off the high chair and it
magically reappearing).
 Separation anxiety is a consequence of this stage and may continue
in varying degrees until 18 months.
Age 1–3 years  Infants begin to develop a sense of self and explore their
(Toddler autonomy. They may become non-compliant for the first time, as
they practise asserting themselves, trying to establish themselves
teething. It is important to seek medical advice if an infant has
persistent febrile illness.
Children’s behaviour is a function of their learning and
development, and so it is reasonable to expect that their
behaviour in the dental environment will also vary.
 The child has limited ability to understand dental
procedures. Nonetheless, with a sensitivity to the child’s
normal emotional development and play expectations, even
without cooperation, an oral examination and some
treatment can often be accomplished without sedation.
 Good rapport with the parents is required, as the dentist
can educate the parent in the importance of sending
positive and appropriate feedback to the infant/child about
the dental experience.
 In the dental room, the clinician may identify an object of
particular ownership such as a doll or another toy, and
praise the child for taking good care of it rather than trying
to remove it.
years – as independent and avoiding situations that make them feel out of
egocentric) control and with a limited sense of self.
 Language develops and ‘No’ becomes a favourite in their repertoire
of words.
 Sharing and cooperative play is meaningless at this stage, as the
‘toddler rules of ownership’ outweigh all concepts, such as: If I see it
it’s mine. If it’s yours and I want it, it’s mine. If it’s mine, it’s mine
and mine only!
Age 3 years  By this age, children are less egocentric and like to please adults.
 They have very active imaginations and like stories; back-and-
forth communication is possible, and children at this age typically
have the capacity for some reasoning.
 In times of stress, they will turn to a parent and not accept a
stranger’s explanation.
Typically, these children feel more secure if a parent is allowed to
remain with them until they have become familiar with the dental
professionals. Then a positive approach can be adopted.
 Giving toddlers lots of little choices (a choice of two at any
time) will assist in enhancing their sense of self and
importance, resulting in greater cooperation.
 Preferences for ‘boy’ and ‘girl’ objects is common at this age:
many toddler boys show interest in cars, trains, the colour
blue and other boys, while many toddler girls show interest
in dolls, fairy dresses, the colour pink and other young girls,
for example. Play remains solitary, however, and is ‘parallel
play’ to their peers.
 The ability to communicate varies according to the level of
vocabulary development, which is expected to be limited.
Thus, the difficulty in communication puts the child in a
‘pre-cooperative’ stage.
 These children are too young to be reached by words alone,
and shyness may mean that the child must be allowed to
handle and touch objects to understand their meaning.
 Children of this age typically should be accompanied by a
parent.
 Liberal use of praise for adherence to requests in the
surgery is indicated, given the child’s desire to please adults.
 Telling stories during the course of treatment may help to
capture the child’s attention and to distract him/her from
any unpleasant aspects of care being provided.
Age 4–5  By this age, children are exploring new environments and
(early relationships in their world. They prefer one-on-one friendships,
childhood as more than one is difficult to manage. Once at school, however,
years) they have to learn to sit quietly in groups and pay attention.
Further development of social skills and regulation of emotions is
occurring while mixing with their peers.
 These children listen with interest and respond well to verbal
directions. They have lively minds and may be great talkers who
are prone to exaggeration. In addition, they will participate well in
small social groups.
 4-year-old children are extremely creative, as fantasy and
imaginary play allows them to work through confounding
problems, emotions and the stressors of daily life. Therefore,
pretend play can open the door to a young child’s thoughts and
worries and provide the dentist with valuable information.
Showing great interest, listening and reflecting back to the child
what they just said or taking on the role of another toy in
conversation with them, will encourage them to explore further.
Age 6–8 years  By 6 years, children are established at school and are moving away
from the security of the family.
 They are increasingly independent of parents and will play without
their parents being in close proximity.
 For some children, this transition may cause considerable anxiety
with outbursts of screaming, temper tantrums and even striking
parents. Furthermore, some will exhibit marked increase in fear
responses.
Age 8–12  At this age, children are part of larger social groups and are
years (the strongly influenced by them. They notice who is accepted and who
middle years) is excluded from groups. With this comes the growing concern of
embarrassment, which they will avoid at all costs. While parents
might wish for them to become leaders, they appropriately become
followers, as this is perceived as healthier and safer.
 At this age, these children can be cooperative patients, but
some may be defiant and try to impose their views and
opinions. They are familiar with and respond well to ‘thank
you’ and ‘please’.
 Promotion of autonomy and the development of self-esteem
by allowing decision- making and choices in their treatment,
and encouraging them to take responsibility for tasks such
as manoeuvring the dental chair, is important.
 Children at this age usually have no fear of leaving their
parents for a dental appointment because they have no fear
of new experiences. They take pride in their possessions,
and comments about clothing can be effectively used to
establish communication and develop a rapport. By this age,
children usually have relinquished comfort objects such as
thumbs and ‘security blankets’.
 This age may be an ideal time to help the child and
parent/caregiver move from the parent/caregiver being in
the surgery to the child being able to go back alone from the
waiting room to the surgery.
 The increased tendency toward fearfulness prompts special
care in working with children at this age, accepting that new
fear(s) may develop, even if the child has been a prior
patient who earlier was comfortable in the dental setting.
 Be cautious to not embarrass the child through criticism of
his/her self-care (e.g. toothbrushing).
 Be patient in not expecting the child to freely share
information without consider- able rapport-building.
 Given the developing capacity to reason, children in this age
range may respond well to explanations about the need to
  As a consequence, children learn to hide their feelings and engage in toothbrushing and flossing on their own, without
thoughts at this time and adopt a ‘cool’ attitude. parental prompting.
 Intellect becomes more important as they develop cognitively and
begin to reason. The pre-teenager becomes concerned with what is
moral and just and becomes more literal (e.g., a parent asks: ‘Pick
up your clothes’. The child picks them up and places them back
down stating, ‘You didn’t tell me where to put them!’).

Adolescence  The adolescent is faced with solving major questions such as: Who  Treating the teenager as his or her own person,
am I? Who am I becoming? Whom should I be? With such tasks in independent from the parent/ caregiver, typically will be
mind, it is understandable that teenagers are often perceived as well received.
self-absorbed, excluding themselves from family and to some  Taking some time to talk about non-dental topics in an
degree, their peers. Many interactions with the teenager tend to ‘adult’ way may be a good way to develop rapport.
result in a narcissistic view of any situation.  Emphasizing the importance of self-dental care to maintain
their smile may be a way to ‘reach’ adolescents in terms of
 Adolescents are on a journey of self-discovery and, not unlike the preventive behaviours.
toddler, are looking for greater autonomy, such as experimenting
with new identities, realities and self-concepts, all of which are
healthy. Experimentation and use of tobacco and other substances
is common.
 Adolescents typically believe they are invulnerable, and that they
will not encounter adverse results from their actions. They do not
expect, for example, that negative health outcomes will result from
tobacco use as ‘other people’ get addicted and only ‘old people’
have health problems.
 Appearance becomes increasingly important during the teenage
years.
 Teenagers often feel that their experiences are unique, so listening
with an open mind, providing independence as would be done
with an adult and supporting them in reaching their goals (within
safety limits), will earn trust and cooperation.
 Greater rapport is gained when the dentist adopts a non-
judgemental, non-

preaching and respectful approach towards the teenager.

Understanding child temperament

There has been a longstanding debate in the literature on child development about the degree to which a child’s development is influenced by ‘nature’ versus ‘nurture’.
Studies suggest that children do indeed enter the world with a characteristic temperament or personality that stays with them to some degree, for the rest of their
life. Thomas and Chess (1977) suggested that there are three basic temperaments that influence later personality:

Easy temperament

These children have a positive mood, regular bodily functions, are adaptable and flexible and have a positive approach to change or new situations.

Difficult temperament

These children are more irritable and intense. They have irregular body functions and take some time to develop feed, play, sleep patterns and routines. They have
difficulty with new situations and adapting to change and tend to withdraw in social settings.

Slow to warm-up temperament

These children have a shy disposition and a low activity level. Initially, they are slower to adapt to new situations but once they are comfortable with their environment
they begin to engage.

Approximately 65% of infants can fit into one of these three categories. The remainder have a mixture of traits.

Dental implications of child temperament

Dentists working with children must use different approaches and techniques, depend- ing on the personality type of the child. Whereas an easy temperament child
may be flexible enough to handle a quick change in plan, a slow to warm-up child may need to be given a longer time to adjust. Difficult children respond best to a
dentist who provides a great deal of structure in a sensitive but confident manner. The slow to warm-up child is best served by dental personnel who are calm, patient
and encouraging (without being demanding).
3. Communication
4. Behavioural shaping technique

5. Desensitisation eg T.S.O
6. Modeling
7. Contigency management