USE OF DIAZEPAM, CHLORPROMAZINE AND ALIMEMAZINE IN

BEHAVIOR MANAGEMENT OF HYSTERICAL AND ANXOIUS PEDIATRIC

PATIENTS.

Valdemoro, C (*)., Rojo-Moreno,J (**)., Catala, M(***).Zaragoza, A(****)

School of Medicine and Dentistry. Valencia. Spain

(*) Pediatric Dentist, Psychiatrist, Associate Professorof Operative Dentistry.(**) Professor of Psychiatry and Professor in charge ofPsychology for Dentists.(***) Professor of Pediatric Dentistry.(****)Associate Professor of Pediatric Dentistry.

Address: e-mail: juan.m.rojo@uv.es ; carlota.valdemoro@uv.es

ABSTRACT

1

To know the response of psychopharmacological drugs in the

behavior management of pediatric dental patients, a sample of 41

children is used and a questionnaire of 20 variables is applied.

The sample is previously divided into two groups: “Anxious Group”

(AG) and “Hysterical Group” (HG). The AG is treated with Diazepam,

while the HG is treated with Alimemazine (children ten years old

or less) or Chlorpromazine (children over ten). The positive

response obtained with these psychopharmacological drugs stands

out in the management of behavior. The seven behaviors which,

basically, characterize the HG are: 1.- “Refusing to Open Mouth”,

2.- “Taking hand to mouth when about to be intervened”, 4.-

“Screaming”, 5.- “Making violent gestures to move the dentist’s

hand away”, 6.- “Kicking”, 7.- “Sitting on the dentist’s chair

with problems”. The discriminating analysis confirms that with

these seven behaviors both groups are clearly distinguishable on

the first visit. Premedicated children with hysterical behavior

respond worse to Anesthesia, Aperture, and to the Rubber Dam than

premedicated children with anxious behavior.

KEY WORDS: BEHAVIOR MANAGEMENT. CHILDREN. PEDIATRIC DENTISTRY.

QUESTIONNAIRES. PSYCHOACTIVE DRUGS. DIAZEPAM. CHLORPROMAZINE.

ALIMEMAZINE.

2

INTRODUCTION.

The purpose of our research has had two aims: firstly , to

evaluate the use of psychopharmacological drugs in controlling the

behavior of children attending a pediatric dental clinic, and to

compare the results depending on the drug used. Secondly, to

determine if using a behavior scale can help us differentiate

between anxious and hysterical behavior.

The first step was to look at the clinical diagnosis to

differentiate between two clinical syndromes:

1.- Symptoms of anxiety, which will, consequently, manifest in

anxious behaviors. 2.- Hysterical symptoms (also called

“Functional”), which result, consequently, in Hysterical

behaviors. The first group (Anxious) includes manifestations such

as “being tense”, “crying”, “hyperventilation”, etc. The second

group (Hysterical) includes behaviors which were already

designated by Krestchmer1 as “Hypobulic”, meaning, children that:

“show uncontrolled excitement”, “have a fleeting reaction”, “hold

on desperately to mother” or “squirm in the dentist’s chair” .

These Hysterical conducts often give rise to disorderly behaviors

such as fleeting (hysterical fleeting), as well as crouching down

on the floor or in a corner. Hypobulic behaviors can be modified

on certain occasions with in situ resources such as “voices of

command” or the hand-over-mouth technique. The next step was to

evaluate the change in behavior at the dental clinic, after

administering the psychopharmacological drugs, and to ascertain

which are the behaviors that characterize the anxious and

hysterical groups respectively. For this purpose the following

Material and Method were used.

3

MATERIAL AND METHOD.

Our sample was made up of 41 children that required dental

treatment. After the first visit we decided that it would be

beneficial to administer psychopharmacological drugs to control

the child’s behavior in the spirit of Ryder2 and Musselman’s3

recommendations.

Two judges, both of them pediatric dentists determined the use of

psychopharmacological drugs according to the clinical

characteristics of the patients (either anxious or hysterical). In

the first visit, the “group” diagnosis was made.

Children presenting, at least, the following three behaviors were

considered, a priori, to be Anxious: 1- Being tense, 2- Having

legs up or muscles contracted, 3- Crying.

Children that present at least two of the following behaviors are

considered, a priori, to be Hysterical: 1- Refusing to sit on the

dentist’s chair, 2- Kicking, 3- Violently moving the doctor’s hand

away, 4- Taking hand to mouth.

The diagnosis of the Anxious or Hysterical child was carried out

by two judges at the same time. One acted as the main judge and

the other acted as assistant judge but did not intervene directly

with the child. The assistant judge carried out the diagnosis

according to what had been observed. Only when both diagnoses

matched , leaving no room for doubt, was the child included in

the study. If there were any discrepancies whatsoever, the child

was rejected.

We have based ourselves on a series of operative characteristics

when making our “diagnosis” since we have sought to establish

two clearly differentiated groups: one where the behaviors were

4

predominantly of the anxious type, and the other group where at

least two behaviors were clearly of the hysterical type.

In all of these cases the Behavior Questionnaire (shown in detail

in Table 1) was performed on their first visit to the clinic. It

was a questionnaire designed by us, in which the selection of the

different variables (or items) was carried out based on our

experience in the field of pediatric dentistry, and according to

the “Rational Selection” method ( worked out among experts acting

as judges). This required joint work between three professional

pediatric dentists (one of which is also a psychiatrist), a

psychiatrist and a psychologist. In this questionnaire, 12

behaviors are evaluated: “Being frightened by the instruments”,

“sitting on the dentist’s chair with problems”, “opening mouth”,

“taking hand to mouth”, “moving head away”, “speaking and

conversing with the pediatric dentist”, “screaming”, “crying”,

“moving the dentist’s hand away”, “kicking”, “having legs up”,

“being tense”.

As indicated on Table 1, this questionnaire is graded from 0 to 2,

depending on how strongly the behavior is manifested.

Therefore, on the first visit, the pediatric dentist carries out

the following courses of action:

1.- Evaluating the dental lesions which have motivated the visit.

2.- Marking with a cross each item on the Scale of Behavior, thus

evaluating the child’s behavior in the dental clinic.

3.- Diagnosing the child as “Anxious” or “Hysterical”, depending

on his/her behavior.

4.- Prescribing the necessary psychopharmacological drug, which

the child will take on his/her next visit. The children considered

5

Anxious (n=25) were treated on their second visit with one dose of

Diazepam (5-15 milligrams), one hour before the dental treatment.

The children considered Hysterical (n=16) were treated with the

Neuroleptic Alimemazine if they are 10 years old or younger, in a

dosage of 1mg/kg of weight, two hours before treatment; if they

are over 10 years old they will be given one 25 mg dose of

Chlorpromazine two hours before treatment.

The procedures, possible discomforts or risks, as well as possible

benefits were explained fully to the human subjects (and/or their

parents), and their informed consent was obtained prior to the

investigation.

On the second visit, -already premedicated-, (in which the dentist

now acts therapeutically within the child’s mouth), the Behavior

Scale is marked again, and the following variables are also

evaluated: 1.- The behavior when given anesthesia, 2.- Reactions

to the rubber dam, 3.- Reactions to cavity opening, 4.- Behavior

during Drilling, and 5.- Effects of premedication (Table 1).

In performing the statistical study, besides the variables of the

conduct scale, groups have been differentiated according to age

and sex. The statistical analysis of the results has been

performed with the aid of the statistical package SPSS (for

Windows, 6.1). Basically, the “t” of “student” has been used when

making multiple comparisons, with the Bonferroni modification;

when having to use non-parametrical samples, the Chi-Square Test

has been used. Last of all, a Discriminating Analysis (Fisher) was

applied to the 41 children before and after premedication.

A standard significance level of 0.05 has been applied.

6

RESULTS.

a/ Descriptive and according to sex.

In the Global Behavior Scale, there is a clear and significant

difference when we compare the global score obtained by the sample

on the first visit, to the score obtained on the second visit,

once the children have been premedicated (Table 2). The

distribution of the sample according to gender were: boys n=19-

46.3%. Girls,n=22- 53.7%. The distribution is quite homogeneous.

On the first visit, there were no significant improvements in

behavior in relation to the gender variable nor, once

premedicated, on the second visit. There are no significant

differences in relation to the age distribution between the sexes.

b/ Comparison according to Age.

Within the range of 3-14 years of age, the relationship between

age and effect of the premedication in children was evaluated,

taking into account 4 possibilities: 1.- Awake and calm (16 cases,

average = 8.62 years old), 2.- Relaxed and responding to orders

(19 cases, average = 7.95 years old), 3.- Awake but confused (5

cases, average = 4.2 years old), 4.- Sleeping and “disconnected”

(1 case, age 5).

Multiple comparisons have been performed between the different

groups, and the only significant differences obtained were

statistical (when looking at the Age variable): in relation to the

group “Awake but confused”, the youngest children were the most

affected by the medication (p<0.01), and belong to this group.

7

c/ Anxious versus Hysterical.

The average score for the anxious group in the first visit was

9.04 (s.d:2.42) and for the hysterical group it was 20.00

(s.d:4.23)

When comparing Anxious to Hysterical children on the first visit,

there are significant differences (Table 3) in seven

manifestations of behavior: a/ “Opening Mouth” b/ “Taking hand to

mouth” c/ “Moving head away when about to be intervened”, d/

“Screaming”, e/ “Making violent gestures to move the dentist’s

hand away” f/ “Kicking” and g/ “Sitting on the dentist’s chair

with problems”. Children with Hysterical behaviors are graded

higher than Anxious children. Therefore, these are the 7 behaviors

that characterize Hysterical children on their first visit.

d/ In relation to the second visit, once the children have been

premedicated:

After premedication, the improvement in behavior management of

both, Children with an Anxious Behavior (CAB) and Children with

a Hysterical Behavior (CHB ), is significant: on the second visit.

(table 2).There was, as well, an interest in knowing which

behaviors improved most comparing both groups. The result shows

that CHB continue to “Move head away when about to be

intervened”, more than the Anxious Group (p< 0.02); “Scream” (p<

0.01), more than the Anxious Group; Last of all, two new behaviors

appear: “Being frightened by the instruments” more than the

Anxious Group (p< 0.01) and “Being tense” more than the Anxious

Group (p< 0.01); fundamentally, this difference is due to the fact

that Anxious children show a spectacular improvement after

premedication.

8

The smallest children were the most “confused” after premedication

(the average was 4.2 years of age). However, the effect of being

“confused” had no relationship with the psychopharmacological drug

used. In other words, children taking Alimemazine were no more

confused than those taking Diazepam (Chi-Square/Yates).

Another aspect that was evaluated, after the premedication, was

how the children reacted to receiving the Anesthesia, placement of

the Rubber Dam, and during the Aperture and Drilling procedures

(Table 4). Children diagnosed as CHB have a worse response to

Anesthesia, Aperture and to the Rubber Dam. There are no

significant differences in relation to Drilling when comparing

Anxious and Hysterical children.

In order to summarize, and with the results obtained up to now,

the group of Hysterical children would be defined by 7 behaviors:

1.- “Refusing to open mouth”, 2.- “Taking hand to mouth”, 3.-

“Moving head away when about to be intervened”, 4.- “Screaming”,

5.- “Making violent gestures to move the dentist’s hand away”, 6.-

“Kicking”, 7.- “Sitting on the dentist’s chair with difficult

behavior.”

The Anxious Group, on the other hand, scores very low in these

behaviors. The average score for each behavior (taking, as before,

0 as the minimum value and 2 as maximum) never reaches 1 in the

Anxious Group, while it is always greater than 1 in the Hysterical

Group.

Both groups (Anxious and Hysterical) “Are frightened by the

instruments”, “Are tense”, “Have legs up or muscles contracted”,

“Cry” and “Speak little and barely establish communication with

the pediatric dentist”. In these behaviors common to both groups,

9

there are no differences of statistical significance between the

groups (t Student).

e/ Applying the Discriminating Function to the results obtained

with the 41 children of our study, we obtained two Function

Values: -4.16406 (Anxious Group), and +6.50635 (Hysterical Group).

The sign + or -, which has no quantitative value, indicates that

these two groups are clearly differentiated.

Looking at the behaviors which fundamentally discriminate both

groups, two constant behaviors appear: 1.- The Hysterical group

“makes violent gestures to move the dentist’s hand away”. (This

variable absolutely discriminates the Hysterical Group).

2.- The Anxious Group, as well as the Hysterical, reach the

maximum score in the behavior: “Being Tense”. (This variable is non-

discriminating).

The next stage consists of finding out the discriminating value of

the ten remaining behaviors. The coefficients of these ten

behaviors are shown on Table 5 (ordered from highest to lowest

“weighting”).

Fundamentally, the 6 behaviors that discriminate both groups are:

1- “Taking hand to mouth”, 2- “Moving head away when about to be

intervened”, 3- “Kicking”, 4- “Screaming”, 5- “Opening mouth”, and

6- “Sitting on the dentist’s chair with problems”. Due to the (+)

sign of these coefficients, the Hysterical Group is the one

fundamentally defined by these behaviors.

Therefore, these 6 behaviors, together with “Making violent

gestures to move the dentist’s hand away” define the Hysterical

Group, confirming the results obtained with the “t” of “student”.

10

The next step consists of applying this Discriminating Function to

the results obtained on the second visit. After premedication, the

value of the Function in the Anxious Group is -1,17859 and, in the

Hysterical Group, it is +1,84155. Hence, the values are very

similar. The children have improved their behavior approximating

normality and both groups are barely distinguishable.

DISCUSSION

The results clearly show the effectiveness of tranquilizers in

Children with Anxious Behaviors (CAB), and neuroleptic medication

in Children with Hysterical Behaviors (CHB). In addition, the

Questionnaire efficiently discriminates the CHB from the CAB.

Klein´s 4 recommendation of treating the children in the afternoon

was always followed.

It is true that the use of sedative substances has been practiced

frequently, 2-5-6-7-8 often combining several of these substances 9-10-11-

12-13 .These two substances (Tranquilizers and Neuroleptics) have

been chosen for comparison because psychiatric science has shown

how a response is more favorable against anxious conduct and

states when providing tranquilizers; the same occurs in Hysterical

behaviors with neuroleptics as indicated by Rojo-Sierra 14 . In

addition, the use of Benzodiazepines has been highly recommended

in the treatment of anxious behaviors, just like Neuroleptics have

been highly recommended in the control of impulsive behaviors in

children as stated by Espiegel15 and Popper16. Neuroleptics have

11

been used as well for sedation and control of nausea/vomiting in

children undergoing dental treatment .17-18-19

No significant differences in behavior were found related to sex

during the first visit, nor in the response to sedative

substances; this disagrees with what Udin,20 found when observing

that girls are more manageable than boys. However, other authors,

like ourselves, find no such differences 21-22.

In relation to the age variable, when multiple comparisons were

made among different groups, the only significant result was found

when this variable was contrasted to the item “awake but

confused”, with a total of five cases in which the average was 4.2

years of age. This was independent of the psychopharmacological

drug used, and it occurred on the smallest children. Although the

youngest children were the ones “confused” after premedication,

their behavior continued to improve in manageability in the same

way as the other age groups, even though their state of

consciousness had decreased. Despite the fact that many research

papers show that behavior management is more difficult with

smaller children 23-24 , in our case, once psychopharmacological

drugs are used, the behaviors of all children are equally

manageable, regardless of age.

On the other hand, different investigations have shown positive

results of Diazepam in behavior management with non-cooperative

children 25-2-11 , but have not made a distinction between hysterical

and anxious behaviors. The results of these studies cannot be

contrasted to our own, since this distinction was made from the

beginning in our study.

12

As Glasrud 26 and Klingherg 23 , among other authors, have pointed

out, it is important to avoid traumatic dental experiences among

children to prevent, as well, the fear of dentists that adults so

often have. The use of tranquilizers and neuroleptics can help in

this task. If types of behavior are differentiated, tranquilizers

and neuroleptics will be more effective in controlling, when

necessary, anxious and hysterical behaviors respectively. In this

line of thinking, we believe that it is possible that

neuroleptics can control anxious behavior. Nevertheless

Benzodiazepines are recommended in the treatment of anxiety due

to their efficacy, speed of effect and easy management. On the

other hand, although the effects of benzodiazepines on

hysterical behavior has not been studied in our research, we have

observed how it can partially sedate hysterical children even

though it does not control the impulsiveness of hysterical

behaviors. The use of neuroleptics has enabled us to deal with

these children without having to use other kinds of physical

restraints.

Conclusions .

1. The use of diazepam has been very positive in the management

of anxious behaviors in pediatric patients. The use of

neuroleptics (Alimemazine and Chlorpromazine) in children with

hysterical behaviors has been equally positive.

2. Seven different behaviors have been identified in hysterical

children.

13

3. Premedicated children with hysterical behavior respond worse to

Anesthesia, Aperture, and to the Rubber Dam than premedicated

children with anxious behavior.. However, they show no more

difficulties than anxious children in behavior management when

obturation is being performed

4. At an operative level, our Behavior Questionnaire is very

useful for identifying hysterical behaviors in children visiting

pediatric dental clinics.

14

TABLE 1 Behavior Questionnaire used in all the cases of our sample, once on the first visit at the same time the group diagnose was made, and the second time on the next visit, during which the dentist applies therapeutic treatment to the premedicated child. The variables “Response to Anesthesia”, “Response to Rubber Dam”, “Behavior during Cavity Opening”, “Behavior during Drilling”, as well as the variable “Effect of premedication”, are only evaluatedon the second visit with the children already premedicated.

BEHAVIORS: 0 points 1 point 2 points

1.- Being frightened by the instruments.

NO AVERAGE YES

2.- Sitting on the dentist’s chair with problems.

NO AVERAGE YES

3.- Opening mouth. YES AVERAGE NO4.- Being tense. NO AVERAGE YES5.- Having legs up or muscles contracted.

NO AVERAGE YES

6.- Making violent movements trying to move the doctor’s handaway.

NO AVERAGE YES

7.- Moving head away when about to be intervened.

NO AVERAGE YES

8.- Taking hand to mouth. NO AVERAGE YES9.- Kicking. NO AVERAGE YES10.- Crying. NO AVERAGE YES11.- Screaming. NO AVERAGE YES12.- Speaking, establishing communication with dentist.

YES AVERAGE NO

-------------------------------------------------

-----------

----------------------

-----------

13.- Response to Anesthesia. Good Average Bad 14.- Response to the Rubber Dam. Good Average Bad 15.- Response to cavity opening. Good Average Bad 16.- Response to drilling. Good Average Bad 17.- EFFECT OF PREMEDICATION -Awake but confused.-Sleeping and “disconnected”.

15

-Relaxed but responding to orders.

DIAGNOSIS ANXIOUS HYSTERICAL

Table 2. Comparison of scores in the scale during first visit vs. scores on the second visit.

HG = Hysterical Group. AG= Anxious Group

First Visit Points

Second visit Points

t-value p(t)

Global Score Average scoreAGAverage scoreHG

13.32 9.0420.00

Global ScoreAverage score AGAverage score HG

3,34 1.60 6.06

13.96 0.0001 14.97 0.0001 12.97 0.0001

16

Table 3. Comparison between groups. Anxious (A) vs. Hysterical (H). Behaviors which differentiate Anxious andHysterical children on the first visit.

BEHAVIORS SIGNIFICANCE OBSERVATIONS Opening mouth pt= 0.0001 “H” children

do not open mouth.

Taking hand to mouth.

pt= 0.0001 “H” take hand to mouth.

Moving head away when about to be intervened.

pt= 0.0001 “H” move head away.

Screaming. pt= 0.01 “H” scream more.

Making violent movements trying to move doctor’s hand away.

pt= 0.0001 “H” move doctor’s hand away.

kicking. pt= 0.0001 “H” kick. Sitting on the dentist’s chair with problems.

pt= 0.002 “H” do not siton dentist’s chair.

17

Table 4. Comparison between Anxious (A) vs. Hysterical (H), on response to the procedure of Anaesthetizing, Cavity Opening, Placement of the Rubber Dam, and Cavity Drilling, already premedicated.

Dental procedure Significance. p(t)

Observations

ANAESTHESIA p= 0.02 Children with Hysterical conducts respondworse to the procedure of Anaesthetizing,

APERTURE p= 0.04 Cavity Opening,RUBBER DAM p= 0.008 and to placement

of the Rubber Dam.

OBTURATION n.s

18

Table 5. The 10 remaining behaviors of the questionnaire and the coefficients (“weightings”), ranked from highest to lowest, are shown below. The first six have a higher weight. In these six conducts, weight is always superior to 0.0. Together with the variable “making violent gestures to move the dentist’s hand away”, the discriminative analysis confirms the 7 behaviors that differentiate the Hysterical from the Anxious group.

BEHAVIOR “WEIGHTINGS”Taking hand to mouth. 0.56668Moving head away when about to be intervened. 0.39694Kicking. 0.18071Screaming. 0.17824Refusing to open mouth. 0.11494Sitting on the dentist’s chair with problems. 0.11245No talking nor establishing conversation with thedentist.

0.03498

Crying. 0.00639Being frightened by the instruments. -0.00469Having legs up or muscles contracted. 0.00207

19

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