Chapter 21  Nonpharmacologic Behavior Management 221

TABLE 21.3: Word picture of a 4-year-old

Emotional development
• Dominates—bossy, boastful
• Hit, grabs for what he wants
• Explosive; destructive
• Loyalties shift frequently
• Cooperative play (with 2 or 3)
• Easily over stimulated, excitable, goes
out of bounds
• Assertive
• Impatient and intolerant in large groups
• A show-off, cocky, noisy
• Insists on what he wants
• Can jump about own height
• Loves to tease, to outwit
• Terrific humor, nonsense loving, silly
Mental development
• Can do two things at once
• Likes variety of materials
• Accepts changes with preparation
• Judges which of two is bigger
• Confuses fact and fancy
• Concepts of life and death
• Attention span: 8 to 12 minutes
• Produces recognizable forms
• Calls people names
• Constructive
• Enjoys silly words, rhymed without meaning
• Dynamic intellectual drive
• Understands simple reasons for thing
• Able to talk to solve conflicts
• Age conscious and birthday conscious
• Comments, criticizes, compares
• Vocabulary about 1500 words
Motor development
• A longer, leaner body built
• Throws large ball, kicks with some accuracy
• Vigorous, dynamic
• Dresses self-except for back buttons, bow
ties
• Can’t set limits—active until exhausted
• Accurate, but rash in body movements
• Sureness and control in finger hand activities
• Can jump about own height
• Lands upright

TABLE 21.4: Word picture of a 5-year-old

Emotional development
• Becoming poised, self-confident
• Harbors wounded feelings
• Copies adult behavior—acts grown up
• Likes companionship with adults
• Plays in groups of 2 to 5 children
• Has to be right
• Enjoys group play, circle games
• Talks about home, reveals family secrets
• Sensitive of ridicule
• Conscious of sex differences of
playmates, sex play
• Accepts and respects authority, will ask
permission
• Growing competitiveness
• Silly, giggling
• May get high, wide, wild
• Enjoys pointless riddles and jokes
Mental development
• Curious about everything
• Attention span: 12–28 minutes
• Seeks information on how and why
• Ready for short trips into community
• Defines familiar objects in terms of their use
• Knows name and address
• Enjoys making up songs, dictating own stories
• Self-centered in thinking
• Uses complete sentences readily
• Counts ten objects
• Likes to display his new knowledge and skills
• Uses big words
• Makes a plan before starting project
• Vocabulary—about 2200 words
Motor development
• Enjoys activities requiring hand skills
• Adult like posture in throwing and catching
ball
• Draws a recognizable man
• Able to skip on both feet
• Learning how to tie a bowknot
• Skill and accuracy with simple tools
• Surging physical drives
• Can sit still for brief periods
• Likes dancing—rhythmic, graceful
• Enjoys jumping, running, stunting

Medical History Family and Peer Influence

When studying a child’s medical experience, it is the
emotional quality of past visits rather than the number of
visits to the physician that is significant. If the patient views
a physician favorably, then the child is likely to have less
apprehension when visiting the dentist. Fears can thus be
transferred from one situation to another; hence preformed
attitude concerning health care can be of prime importance.
Maternal Anxiety
In past years, it has been customary for mothers more often
than fathers to accompany children on a visit to the dentist,
therefore, maternal anxiety was considered important. Highly
anxious mother had a negative influence on the child.
Socioeconomic status of the family directly affects child’s
attitude toward the values of the dental health process. Those
of low socioeconomic 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 cooperative.
On the other hand if financial and educational means are
ample, families value good dental health easily established in
preventive program.
Dental Office Environment
Bohuslov (1970) stated that psychologic preparation of the
child is based on the physical environment. Since the child
222 Section 5  Behavioral Pedodontics

may enter the dental office with some fear, the first objective
of the dentist should be to put the child at his ease and
make him realize that his experience is not unusual. Finn
summarized the following factors related to the dental office
which influence child’s behavior:
• Waiting room should be made in respect to home
environment.
• Make the reception room comfortable, so that the room is
not foreign to them.
• Have library with books for children of all ages.
• Simple but sturdy toys must be kept to amuse very small
children.
• A handy record player with well-chosen records will
provide comfort for a frightened child.
• Appointment cards and announcements should be made
attractive to children.
• A sketch of some cartoon on card helps.
• Operating room may be made more appealing to the child
if a few pictures on the wall are suggestive of child at play.
A portrait of a carefree and laughing child is good.
• Have an assistant skilled in making animals object out of
cotton rolls.
• Try to avoid having child patient, see adults in pain or
sight of blood on others.
Growth and Development
A child’s chronological age plays a significant role in growth
and developmental patterns. Younger the child, more atypical
will be the response. The intellectual age of 3 years signifies a
maturational readiness to accept dental treatment. Different
age groups will show different behavior patterns as explained
in the word picture charts.
Fundamentals of behavior management
• Team attitude
• Organization
• Positive approach
• Truthfulness
• Tolerance
• Flexibility
Personal Factors
Temperament, general fearfulness are some of the personal
characters which are known to influence the behavior of the
child. Although these are to influence the child’s behavior
the most, personal characters are also affected by the
environmental factors.
Environmental Factors
Various environmental factors like age of the child,
socioeconomic status, family situation, frequent exposure
to invasive medical care, past experience of operative dental
care, etc. have been identified to influence the child’s behavior.
However, parental dental fear has been noted to be the most
influencing factor amongst all environmental factors.
Other Variables
Stephen Wei explained that many other variables affect the
child in dental office like socioeconomic status, culture, sex,
sibling relation, number of children, presence of parent and
attitude of dentist.

Scientific research pertaining to child behavior in dental office

• According to Klingberg L and Raadal M dental fear and behavior are multifactorial and can be broadly classified into personal characters,
environmental factors or situational factors.
• Locker D (1996), Tenberge M (2001) and Versloot J (2009) concluded that past medical and dental experiences are the most prominent of
all the factors.
• Milgrom P (1997) found out that fear of injections (Belonephobia) is major cause for fear and uncooprative behavior in children.
• Lee (2008) found out that younger children exhibit more dental fear than elder. In addition, invasive and painful experience during first
dental visit contributed significantly for the disruptive behavior in children.
• According to Davey (1989) traumatic experiences during first dental visit are more likely to cause to dental anxiety in children
• Rachman S (1977) in his conditioning theory of fear suggested that objective experiences like previous visit to pediatrician or experience
during first dental visit play a greater role than subjective experiences due to siblings and child rearing practices in the family.
• Klingberg G (2007) observed cooperative children were fearful and uncooperative children were nonfearful. This indicated that the
children with behavior management issues need not always be fearful.
• Kyritsi (2009) studied the behavior of Greek children and suggested that behavior of the child was not related to gender of the child
but related to age of child. Children with siblings or in joint families are known learn patience, tolerance and tend to be cooperative.
However, in nuclear families parents play a major role in shaping the behavior.
• Gao (2013) studied dental fear and anxiety in children and adolescents and concluded that DFA has multifaceted manifestations, impacts,
and origins, some of the themes only become apparent when using internet social media like You Tube.