Psychological Development in Pediatric Dentistry

1. Theories of psychological
development
Dr. Edward Kabubei
2021

2. Reading
• Shobha Tandon Volume 1
• Chapter 14- Emotional Development
• Chapter 15-Theories of child psychology

3. Stages of child development
• Infancy (covering birth to age two)
• Early Childhood (covering ages two to seven)
• Middle Childhood (covering ages seven to eleven)
• Adolescence (covering ages eleven to twenty-two)

4. SIGMUND FREUD
• Sigmund Freud (1856-1939) was a Viennese doctor who came to believe
that the way parents dealt with children's basic sexual and aggressive
desires would determine how their personalities developed and whether or
not they would end up well-adjusted as adults.
• Freud described children as going through multiple stages of sexual
development, which he labeled
1. Oral
2. Anal
3. Phallic
4. Latency
5. Genital.

5. Sigmund Freud I
• Oral phase- children are focused on the pleasures that they receive from
sucking and biting with their mouth.
• Anal phase- focus shifts to the anus as they begin toilet training and
attempt to control their bowels
• Phallic phase- focus moves to genital stimulation and the sexual
identification that comes with having or not having a penis. *(Question
what is Oedipus complex?)
• Latency- sexual urges and interest were temporarily nonexistent
• Genital- stage in which adult sexual interests and activities come to
dominate.

6. Sigmund Freud II
• Freud thought that all babies are initially dominated by unconscious,
instinctual and selfish urges for immediate gratification which he labeled
the “Id”
• As babies attempt and fail to get all their whims met, they develop a more
realistic appreciation of what is realistic and possible, which Freud called
the "Ego"
• Over time, babies also learn about and come to internalize and represent
their parents' values and rules. These internalized rules, which he called the
"Super-Ego", are the basis for the developing child's conscience that
struggles with the concepts of right and wrong and works with the Ego to
control the immediate gratification urges of the Id.

7. ERIK ERIKSON’S PSYCHOSOCIAL THEORY
• Erik Erikson (1902-1994) used Freud's work as a foundation to develop a
theory about human stage development from birth to death.
• Erikson focused on how peoples' sense of identity develops; how people
develop or fail to develop abilities and beliefs about themselves which
allow them to become productive, satisfied members of society.
• Erikson's theory combines how people develop beliefs psychologically and
mentally with how they learn to exist within a larger community of people,
it is thus called a 'psychosocial' theory.

8. Erik Erikson
The stages are
1. Trust versus mistrust
2. Autonomy versus shame and doubt
3. Initiative versus guilt
4. Industry versus inferiority
5. Identity versus identity confusion
6. Intimacy versus isolation
7. Generativity versus stagnation
8. Integrity versus despair.
Note that
a)Each stage is associated with a time of life and a general age span.
b)For each stage, Erikson's theory explains what types of stimulation children
need to master at that stage in order to become productive and well-adjusted
members of society
c) Erikson explains the problems and developmental delays that can result when
this stimulation does not occur.

10. LAWRENCE KOHLBERG
• Lawrence Kohlberg (1927-1987) described three stages of moral
development which described the process through which people learn to
discriminate right from wrong and to develop increasingly sophisticated
appreciations of morality.
• He believed that his stages were cumulative; each built off understanding
and abilities gained in prior stages.
• According to Kohlberg, moral development is a lifelong task, and many
people fail to develop the more advanced stages of moral understanding.

11. Lawrence Kohlberg
1. ‘Pre-conventional' level
Describes children whose understanding of morality is essentially only driven
by consequences. Essentially, "might makes right" to a pre-conventional
mind, and they worry about what is right in wrong so they don't get in
trouble.
2. Conventional morality
Describes people who act in moral ways because they believe that following
the rules is the best way to promote good personal relationships and a
healthy community.
A conventional morality person believes it is wrong to steal not just because
he doesn't want to get punished but also because he doesn't want his friends
or family to be harmed.

12. Lawrence Kohlberg
3. Post-conventional level
Describes people whose view of morality transcend what the rules or
laws say. Instead of just following rules without questioning them
Post-conventional' stage people determine what is moral based on a
set of values or beliefs they think are right all the time

13. JEAN PIAGET
• Swiss psychologist Jean Piaget (1896-1990), created a cognitive-
developmental stage theory that described how children's ways of thinking
developed as they interacted with the world around them. Infants and
young children understand the world much differently than adults do, and
as they play and explore, their mind learns how to think in ways that better
fit with reality.
• Piaget's theory has four stages:
1. Sensorimotor
2. Preoperational
3. Concrete operational
4. Formal operational.

14. Jean Piaget
I Sensorimotor (0-2 years)
Children are just beginning to learn how to learn. Though language
development, and thus thought, does begin during this time, the more
major tasks occurring during this period involve children figuring out how to
make use of their bodies. They do this by experiencing everything with their
five senses, hence "sensory," and by learning to crawl and then walk, point
and then grasp, hence, "motor.“
II Pre-operational (2-7 years)
children start to use mental symbols to understand and to interact with the
world, and they begin to learn language and to engage in pretend play.

15. Jean Piaget
III Concrete operational (7-11 years)
Children gain the ability to think logically to solve problems and to organize
information they learn. However, they remain limited to considering only
concrete, not abstract, information because at this stage the capability for
abstract thought isn't well developed yet.
IV Formal operation (11+ years)
Adolescents learn how to think more abstractly to solve problems and to
think symbolically, e.g., about things that aren't really there concretely in
front of them.

16. URIE BRONFENBRENNER
• Urie Bronfenbrenner (1917-2005) developed the ecological systems
theory to explain how everything in a child and the child's environment
affects how a child grows and develops.
• He labeled different aspects or levels of the environment that influence
children's development, including the
1.Microsystem
2.Mesosystem
3. Exosystem
4. Macrosystem.

17. Urie Bronfenbrenner
• Microsystem
The microsystem is the small, immediate environment the child lives in. This
include any immediate relationships or organizations they interacts with,
such as their immediate family or caregivers and their school or daycare.
How these groups or organizations interact with the child will have an effect
on how the child grows; the more encouraging and nurturing these
relationships and places are, the better the child will be able to grow.
Furthermore, how a child acts or reacts to these people in the microsystem
will affect how they treat her in return.
Each child's special genetic and biologically influenced personality traits,
what is known as temperament, end up affecting how others treat them

18. Urie Bronfenbrenner
• Mesosystem
Describes how the different parts of a child's microsystem work together for
the sake of the child. For example, if a child's caregivers take an active role in
a child's school, such as going to parent-teacher conferences and watching
their child's soccer games, this will help ensure the child's overall growth. In
contrast, if the child's two sets of caretakers, mom with step-dad and dad
with step-mom, disagree how to best raise the child and give the child
conflicting lessons when they see him, this will hinder the child's growth in
different channels.

19. Urie Bronfenbrenner
• Exosystem
Includes the other people and places that the child herself may not interact
with often herself but that still have a large effect on her, such as parents'
workplaces, extended family members, the neighborhood, etc.
For example, if a child's parent gets laid off from work, that may have
negative affects on the child if his/her parents are unable to pay rent or to
buy groceries; however, if his/her parent receives a promotion and a raise at
work, this may have a positive affect on the child because her parents will be
better able to meet his/her physical needs.

20. Urie Bronfenbrenner
• Macrosystem
The largest and most remote set of people and things to a child but which
still has a great influence over the child.
The macrosystem includes things such as the relative freedoms permitted by
the national government, cultural values, the economy, wars, etc. These
things can also affect a child either positively or negatively.

21. Childhood mental disorders
• Intellectual disability is a specific type of disability. It is caused by
limited mental capacity (intelligence). These limitations make it
difficult for someone to care for themselves without additional
support.
• The Diagnostic and Statistical Manual of Mental Disorders of the
American Psychiatric Association (APA, 2013) lists the three main
criteria for intellectual disabilities:
1. Significant limitations in cognitive capacity (mental abilities)
2. Significant limitations in adaptive functioning (conceptual skills, social skills,
and practical life skills)
3. The problems started before age 18.

22. Why does it matter?
• Limited mental capacity makes it difficult to:
1. Develop important mental abilities. This includes reasoning, planning,
thinking, and judgment.
2. Learn new things. The ability to learn is a very important mental ability. We
learn new information and skills in school. We learn from our past mistakes. We
learn how to do many things by watching others. When this ability to learn is
lacking, it causes many challenges in everyday life.
3. To acquire the skills needed for independent living. Without these skills, it is
hard to live in a safe and socially responsible manner.
4. Develop at the same pace as other children. They usually sit, walk, and talk
much later than other children. The delayed development means they do not
act their age.

23. Causes of mental disabilities
• They can be grouped into four categories
1. Medical conditions;
2. Brain injury;
3. Genetic conditions;
4. Psychiatric conditions.
The leading causes however are: Autism, Down syndrome, Fragile X
syndrome, and fetal alcohol syndrome or FAS
Remember:
• To differentiate between intellectual disability vs global developmental delay
• Note that Intellectual disabilities require independent support and education plans

24. Causes of mental disabilities
Medical conditions Brain injury Genetic conditions Psychiatric
Prenatal exposure to
alcohol and other drugs
Lead
Mercury
Radiation
Toxoplasma from cat
faeces
Hepatitis B
Syphillis
Herpes simplex II
Shaking
Dropping
Always use a car seat
Wear safety gear when
skating and riding bikes
like helmets and arm
pads
Down syndrome
* Fragile X syndrome
Autism spectrum
disorder
* FXS is caused by changes in a gene that scientists called FMR1 gene when it was first
discovered. The FMR1 gene usually makes a protein called FMRP. FMRP is needed for brain
development. People who have FXS do not make this protein.

25. Down syndrome (trisomy 21)
• A flattened face, especially the bridge of the nose
• Almond-shaped eyes that slant up
• A short neck
• Small ears
• A tongue that tends to stick out of the mouth
• Tiny white spots on the iris (colored part) of the eye
• Small hands and feet
• A single line across the palm of the hand (palmar crease)
• Small pinky fingers that sometimes curve toward the thumb
• Poor muscle tone or loose joints
• Shorter in height as children and adults

26. Down syndrome
• Sub types
1. Trisomy 21 (95% each cell in the
body has 3 separate copies of
chromosome 21 instead of the
usual 2 copies
2. Translocation down syndrome is
where the extra chromosome 21
translocated to a different
chromosome
3. Mosaic down syndrome(a
combination)
• Screening
• Blood works & ultrasound
• Diagnostic
• Chronic villus sampling-
examines material from the
placenta
• Amniocentesis-
• Percutaneous umbilical
sampling

27. Down syndrome

28. Autism spectrum disorder
• Neurological disorder characterized by the presence of persistent
(ongoing) communication and social issues. It is a developmental disorder,
which begins in early childhood and continues throughout life. Cognitive
and social skills are typically developmentally delayed compared to their
peers without the disorder but motor skills develop in a more typical way.
Communication Patterns/ Behavioural
Difficulty in social and emotional interactions
with others
Challenge using nonverbal communication
skills
Challenges developing, maintaining and
understanding relationships with others.
Stereotyped or repetitive body movements
Insistence on a set routine that cannot be changed
Highly restrictive interests that are strongly focused on
either a lot of interest or no interest in sensory aspects of their
surrounding environment.
A tendency towards isolation
Difficulty making eye contact
Inability to develop appropriate peer relationships.

29. Attention deficit and disruptive behaviour
disorders
• Children who have chronic difficulties in maintaining attentional focus,
completing work, being impulsive, or repeatedly engage in antisocial
behaviors such as lying and cheating may have one or more Attention-
Deficit and Disruptive Behavior Disorders. The disorders in this category
include
1. Conduct Disorder,
2. Attention-Deficit Hyperactivity Disorder
3.Oppositional Defiant Disorder.
• These three disorders are grouped together because of similarities
between symptoms and prevalence rates For example, children with these
disorders often have academic difficulties, poor social skills, and impulsivity
(i.e., a tendency to act without thinking through potential consequences).
• In addition, boys far exceed girls in terms of rates of occurrence (although
some researchers suggest that girls with ADHD may be overlooked
because they tend to be more inattentive than hyperactive).

30. Conduct disorder
• It is one of the most frequently diagnosed mental disorders
• Children with Conduct Disorder:
1. Act aggressively in a way that causes or threatens to cause physical harm to
others
2. Cause serious property damage even if they are not actually aggressive
towards other adults or children,
3. Steal, and are deceitful
4. Frequently violate rules.

31. Symptoms of conduct disorder
1. Bullying, threatening, or intimidating behavior towards other children
2. Frequent starting of physical fights
3. Use of weapons or tools capable of causing serious physical harm to people or
property (e.g., bricks, bats, broken bottles, knives, guns)
4. Physical cruelty toward animals or people
5. Stealing while confronting a victim (e.g., mugging, purse snatching, armed
robbery)
6. Physical violence towards others (in the form of rape, assault, homicide, etc.)
7. Destruction of property (e.g., fire setting, breaking of windows, breaking into
homes, buildings or cars)
8. Frequent and manipulative telling of lies or breaking of promises in order to
obtain goods, favors, or to avoid debts or obligations (e.g., "conning" people)
9. Staying out at night despite parent's curfew rules (before the age of 13)
10. Repeatedly running away from home, or running away from home for a lengthy
period of time
11. Use of alcohol or drugs
12. Truancy (skipping school) before the age of 13

32. Questions
• What is the importance of child psychology to paediatric dentistry (10 marks)
• Compare and contrast classical conditioning (Pavlov 1927) & Operant conditioning
(Skinner 1938) (10 marks)
Ref: figure 15.6 Shobha Tandon vol I pg 222

33. Further reading
• Social learning theory (Bandura 1963)
• Maslow hierarchy of needs (1954)
Discuss how all these theories fit in to the practice of paediatric
dentistry that is the point of learning the theories

34. Relevance….why you need to know this…
• The theories discussed here will be applied and relied upon as
assumptions as we study
• Behavioural science
• Behaviour management
THE END