CHILD PSYCHOLOGY /certified fixed orthodontic courses by Indian dental academy

CHILD PSYCHOLOGY

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CONTENTS
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INTRODUCTION.
DEFINITIONS.
THEORIES OF CHILD PSYCHOLOGY.
CLASSIFICATIONS.
EMOTIONAL DEVELOPMENT.
BEHAVIOR.
PSYCHOLOGICAL MANAGEMENT
MOTIVATION AND COOPERATION.
PATIENT COMPLIANCE
CONCLUSION.
REFERENCES

WHY PSYCHOLOGY???
 Psychological development is a dynamic process
 Governed by genetic, familial, cultural,
interpersonal & interpsychic factors
 Dentist- “Parent Surrogate”
 Need to understand psychological development
to relate & guide effectively

Definitions
 Psychology: The science of the human soul;

specifically, the systematic or scientific knowledge of
the powers and functions of the human soul, so far
as they are known by consciousness; a treatise on
the human soul.
 Child psychology: The branch of psychology that

studies the social and mental development of children

- U.S. National Library of Medicine

Definitions…
 Emotions: An effective state of consciousness in

which joy, sorrow, fear, hate or the likes are
expressed


Definitions…
 Behavior- any change observed in functioning of

organisms.

 Behavior management- means by which dental

team effectively and efficiently instills a positive
dental attitude in child.
-- Wright, 1975


Importance of child psychology
 Better understanding of the child

 Know problems of psychological origin
 Deliver dental service in a meaningful manner
 Establish effective communication


Importance of child psychology
 Gain confidence of child & parents

 Better teaching of primary & preventive care
 Effective treatment planning and execution
 Provide a comfortable environment


Classification
Theories of child
psychology

PSYCHODYANAMIC

Psychosexual theory
Psychosocial theory
Cognitive theory

BEHAVIOUR LEARNING

Classical conditioning theory
Operant conditioning theory
Social learning theory
Hierarchy of social needs

MARGARET S MAHLER’S THEORY OF DEVELOPMENT

 Psychodynamic theories:
 Psychosexual theory- Sigmund Freud (1905)
 Cognitive development theory- Jean Piaget
(1952)
 Psychosocial theory- Eric Erickson (1963)

 Behavioral theories:
 Classical conditioning – Pavlov (1927)
 Operant conditioning – Skinner (1938)
 Hierarchy of needs – Masler (1954)
 Social Learning theory – Bandura (1963)

Psychosexual/Psychoanalytical Theory

Sigmund Freud (1905)
 Attempts to explain the

personality & psychological
disorders .
 Personality to originate from
biological roots, as a result of
satisfaction of set of instincts
of which sexual instinct is

important.

Psychosexual/Psychodynamic Theory
• Described 6 stages–

•

oral
anal
urethral
phallic
latency
genital

At each stage sexual energy invested in particular part
is called an erogenous zone.

• Human mind–

topographic model
psychic model/psychic triad


Topographical model
 MIND AS AN ICEBERG…

Consists of….. ,,,,,,,
conscious,
preconscious &
subconscious mind


Only 10% of an iceberg is visible (conscious)
whereas
the other 90% is beneath (unconscious)

Conscious mind
 The conscious mind is where

we are paying attention
at the moment…
 Only our current thinking processes and objects of
attention
 Constitutes a very large part of our current
awareness


Preconscious mind
 Ordinary memory & knowledge
 Those things of which we are aware, but where we

are not paying attention
 Deliberately bring them into the conscious mind by
focusing


Unconscious/Subconscious mind
 The process and content are

out of direct reach of the
conscious mind.
 Thinks and acts independently
 Dump box for urges, feelings
and ideas
 Exert influence on our actions and our conscious
awareness


PSYCHIC TRIAD/MODEL
SUPER
EGO

EGO

ID


Structural mind
 An individual’s feelings, thoughts, and behaviors are

the result of the interaction of the id, the ego and the
superego


ID – Pleasure principle
 Basic structure of personality

which serves as reservoir of
instincts or mental representative.
 Born with it.

 As newborns, it allows us to get our basic needs met
 Wants whatever feels good at the time, with no

consideration for the reality of the situation
 Strives for immediate pleasure and gratification

Ego
 The rational part of the mind.
 Develops out of ID in 2-6 month, when infant distinguish

between itself and outside world.
 Uses secondary processes (perception, recognition,

judgment and memory)
 Its governed by -- “Reality principle”

 REALITY PRINCIPLE -- Developed after birth , expands

with age and it delays modifies and controls ID impulses on
realistic level.

Super ego
 Prohibition learned from environment ( parents & society)
 Acts as censor of acceptability of thoughts , feelings and

behavior
 Determined by regulations imposed upon child by

parents , society and culture.
 Its internalized control which produces feelings of shame

and guilt.

 In a healthy person the ego is the strongest

it can satisfy the needs of the id
not upset the superego
still take into consideration the reality of every situation

Ego defense
mechanisms
 These are tactics which the Ego develops to help

deal with the ID and the Super Ego
 All Defense Mechanisms share two common
properties :
- They often appear unconsciously.
- They tend to distort, transform, or
otherwise falsify reality

EGO DEFENCES
ANXIETY

When become overwhelming , EGO must defend itself.

It does so consciously by blocking impulses EGO
DEFENCE
Distorting them in most acceptable manner MECHANISMS


Displacement:
 Redirecting our impulses (often anger) from the real

target (because that is too dangerous) to a safer but
innocent person
 Student
scolded by teacher.
shout at juniors
stamping feet

Projection:
 Attributing one's own unacceptable thoughts,

feelings, impulses to others.
 Person having aggressive feelings towards others
may find it unacceptable to admit he/she have such
feelings

So they project as others have aggressive feelings
towards him/her.

Reaction formation
 Reversal of our feelings, overacting in the opposite

way to the fear.

Loose temper

Laugh to prevent anxiety


Regression:
 Giving up of mature problem-- solving methods in

favor of child like approaches to fixing problems


REPRESSION
PRIMARY REPRESSION

PRIMAL REPRESSION

Expulsion of thought
and memories that
might provoke anxiety
from conscious mind

Process by which
hidden ID impulses are
blocked from ever
reaching
consciousness.

Past painful dental experience --- avoid thinking about painful event --repress anxiousness

Rationalization:
 Giving excuses for shortcomings and thereby

avoiding self-condemnation, disappointments, or
criticism by others

Poor performance in exam

blame teacher


DENIAL
 Person may deny(refuse) some aspect of reality.

Big ulcer in mouth

Diagnosed as carcinoma
Not able to tackle, consult another doctor for denial of
diagnosis.


Psychosexual Stages of Development
 Failures to set satisfying needs/goals at any stages

of psychosexual development leads to the individual
partially fixed at these levels which are evident by
various pathologic traits and in adulthood showing
these signs in various forms.


Oral Stage (0 - 1.5 yrs )
 Erogenous Zone in Focus: Mouth
 Gratifying Activities: eating, sucking,

gumming, biting & swallowing
 The mother's breast not

only is the source of food
& drink, but also represents
her love
 Warm, trusting &

affectionate relationship

Oral fixation

 Both insufficient and forceful feeding can result in

fixation in this stage
 Symptoms of Oral Fixation:
 Smoking
 Constant chewing of pens, pencils
 Nail biting
 Overeating
 Sarcasm ("the biting personality")
 Attention seeking behavior
 Aggressive, dominant

Anal Stage (1.5 – 3 yrs)
 Erogenous Zone in Focus: Anus

 Gratifying Activities: Bowel movement and the

withholding of such movement
 Toilet training

 Discover their own ability to control
 Child realizes his control over his

needs and practices it with a sense
of shame.

Anal Fixation
Anal-Expulsive
Personality
If the parents are too
lenient, the child will
derive pleasure and
success from the
expulsion
Are excessively sloppy,
disorganized, reckless,
careless, and defiant


Anal-Retentive
Personality
If a child receives
excessive pressure and
punishment ,will
experience anxiety over
bowel movements
Very careful, stingy,
withholding, obstinate,
meticulous

URETHRAL STAGE (3-4 yrs)
 Transition between anal & phallic
 Derives pleasure by exercising control over urinary

sphincter
 Objectives similar to anal stage

 Loss of urethral control - shame


Phallic Stage(4-5 yrs)
 Probably the most challenging

stage in a person's psychosexual
development
 "Oedipus Complex" ( boy – mother )
 "Electra Complex” ( girl – father )
 Castration Anxiety
 Penis envy

 Consolidation of ego
 Differentiating between sexes

Phallic Stage
Objectives:
 Child realizes the sexual qualities without
embarrassment.
 Resolution of the stage in regulation of drive
impulse.
Pathology:
if above mentioned characters are not resolved the
balance between male and female roles does not
develop.


Latency Stage(6-12y)

 Sexual feelings are suppressed to allow children to

focus their energy on other aspects of life
 Is a time of learning, adjusting to the social

environment outside of home, absorbing the culture,

forming beliefs and values

Latency Stage
 Resolution of any defects
 Maturation of ego
 Greater control over instincts
 Consolidation of sex roles

 Mastery over skills
 Phase ends in puberty
 Lack of inner control – immature behaviour and

decreased developmental skills.


Genital Stage (puberty onwards)
 Erogenous Zone in Focus: Genital
 Gratifying Activities: heterosexual

relationships
 Interaction with the Environment:


Marked by a renewed sexual interest and desire, and
the pursuit of relationships.



Acceptance of adult role, Social expectations & values,

mature personality.


Fixation
 If people experience difficulties at this stage, and

many people do, the damage was done in earlier
oral, anal, and phallic stages .

 Unresolved traits from previous phases seen in a

modified form.


WHAT IS GOOD ABOUT THIS THEORY?
 One of the first theories proposed in psychology

 Stage wise classification help us to relate to patients

well
 Covers the psychological development of the entire

lifespan
 Role of biology and society have been highlighted
 Concept of ego defenses was very practical

WHATS NOT SO GOOD ABOUT THIS
THEORY?
 Based only on the sexual drive
 Based on studies conducted on few patients

 Complicated and not very practically applicable
 Has been a source of constant criticism and debate

(sexuality, oedipus complex)
 Most of the work based on psychological patients

PSYCHOSOCIAL THEORY: ERIK
ERIKSON 1963
 Infancy

childhood

old age

 Development depends on child’s instincts and

responses of those around him.
 Unresolved issues from early stages of life affect

person’s ability to deal with subsequent visits.

 8 STAGES OF LIFE CYCLES : TURNING
POINTS /PERIODS

PSYCHOLOGICAL
CRISIS


1. Basic trust Vs basic mistrust ( hope )
Birth- 18 months
 First trust of INFANT

MOTHER ( caregiver)

Well handled

adly handled

Nurtured
Loved
Develops trust, security
basic optimism.

Becomes insecure
And mistrustful.

Maternal Deprivation

** SEPARATION ANXIETY- do the treatment in presence of
parents.

** Dental team should gain confidence of child


2. Autonomy Vs Shame( will ) 18
months- 3yrs
 TODDLER begins to push for INDEPENDENCE
 Terrible two’s.
 Well parented child

Sure of himself-autonomy

 Failure to develop --- developments of doubt??????
 "From a sense of self-control without a loss of self-

esteem comes a lasting sense of good will and pride;
from a sense of loss of self-control and foreign overcontrol come a lasting propensity for doubt and shame”
-- ERIKSON

3. Initiative Vs Guilt(purpose) 3-6 yrs
 Child becomes more assertive ; resulting conflict cause GUILT .

HEALTHY CHILD LEARNS
 to broaden skills.
 cooperative with others.
 to lead as well as follow
IF IMMOBILIZED BY GUILT
 Fearful
 depends always on adults
 restricted play skills and imagination.

Make first dental visit as new adventure.,,, if it fails lead sense of guilt
in child


4.Industry Vs Inferiority ( competence)
7-11 yr
 Child learns basic culture skills – school skills
 The child who, because of his successive and successful

resolutions of earlier psychological factors is trusting,
autonomous , initiative and enough to be industrious.
 Orthodontic treatment often begins in this stage.
 Cooperation – understanding of needs

positively reinforce the needs.
 Fails – mistrusting child- doubt the future. Shame and

guilt filled child will experience defeat and inferiority.

5. Identity Vs Role Confusion(Fidelity)
12-17 yrs
 Child now is ADOLESCENT.
 Learns how to answer satisfactorily and happily the

questions WHO AM I?????
WHAT SHALL I BECOME?????

 Behavior management can be challenging in

ADOLESCENT.
 Orthodontic treatment in this stage carried out only

he/she wants, not the parents at this stage. Approval
of peer group is extremely important.


6.Intimacy Vs Isolation( love)
 The successful YOUNG ADULT.
 Intimacy

good marriage.
friendship.

 In this stage external appearance is very

important.
 Young adults may seek orthodontic treatment by

internal motivation

7.Generative Vs Stagnation(care)
 In adulthood, the psychosocial crisis demands

generatively, both in sense of marriage and
parenthood.
 Working productively and creatively.


8.Integrity Vs Despair(Wisdom)
 MATURE ADULT.
 Peak of adjustments, integrity.
 He/she trusts, independent and dares the new.
 Works hard.
 Finds well defined role in life.
 Develops self concept which is happy.

PSYCHOSOCIAL THEORY
MERITS
 Age wise,, so easy to

DEMERITS
 Based on extreme ends

apply to any stage.
 Simple and

comprehensive to
understand.


of personality.

COGNITIVE DEVELOPMENT THEORY- JEAN PIAGET
(1952)
 How children and adolescent think and acquire
knowledge.
 Derived from direct observation of children and

questioning them.
 Environment does not shape child behavior, but

child and adult actively seek to understand the
environment.
 A child incorporates or assimilates events within the

environment into mental categories called cognitive
structures.

Adapt to new
information

Assimilation
•Reinterpret new
experiences so they
EQUILIBRATION
fit into old ideas.
•Existing ideas don’t
change, stay same

Accommodation
•Change old ideas so
they can adapt to new.

• Change current ways
of thinking/ideas so as
to add new knowledge

???????? Bird -- Flying object – Bee ??????

Piaget’s Periods of Cognitive Development
Birth to 2
years

Sensori-motor

Uses senses and
motor skills, items
known by use

Object
permanence
learned

TOY

2-6 yrs

Pre-operational Symbolic thinking,
language used;
egocentric
thinking

Imagination/
experience grow,
child de-centers RADIOGRAPH

7-11 yrs

Concrete
operational

Logic applied, has
objective/rational
interpretations

Conservation,
numbers, ideas,
classifications

Formal
operational

Thinks abstractly,
hypothetical ideas
(broader issues)

Ethics, politics,
social/moral
issues explored

12 yrs to
adulthood

Focus on organization and adaptation

RETAINER

ORTH
TREAT

Cognitive development theory
MERITS
 Most comprehensive.

DEMERITS
 Underestimates ability.
 Overestimates age

differences in thinking.
intellectual development.  Vagueness about
change process.
 Underestimates role of
social environment.

 Learn much about child’s


Classical conditioning – Pavlov (1927)
 Russian psychologist Ivan Petrovich Pavlov – first to

study conditioned reflexes experimentally.
 Demonstrated how learned associations were

formed by various events in an organisms
environment.
 Pavlov’s psychic reflex called as conditioned reflex

by experiment.


Classic Ivan Pavlov experiment
A simple three step example which shows the
important elements of conditioning:
 Step 1: Before conditioning

Salivation – Unconditional response or unconditional
reflex

 Step 2: The conditioning process

Neutral
stimulus

Unconditional
stimulus

Note: Repetition of this is done at each time

 Step 3: After conditioning


How can we apply to Dentistry???....
 First visit

White coat
(Neutral stimulus)
Pain of injection
(Unconditioned stimulus)

pain of injection
fear and crying
(Response)

 Second visit

Sight of white coat
(Conditioned stimulus)

Pain of injection


pain of injection
(Unconditioned. Stimulus)

fear and crying
(Response)

Once conditioned response has established,, its necessary to
reinforce it occasionally to maintain it.

ACQUISATION -- GENERALIZATION -- EXTINCTION -- DISCRIMINATION


Operant Conditioning Theory
 SKINNER B.F ( American psychologist)
 Also called as Instrumental Learning.
 Extension of classical conditioning.
 Consequence of a behavior is in itself a stimulus that affects

future behavior.
 Behavior that controls or operates environment is called as

OPERANT.
 REINFORCEMENT is critical factor in learning and

development of www.indiandentalacademy.com
personality.

 Four basic types of operant conditioning:

(distinguished by the nature of the
consequence.):
1. Positive reinforcement
2. Negative reinforcement
3. Omission
4. Punishment


:
Positive reinforcement
A pleasant consequence follows a response.
A child is given a reward such as a toy for
behaving well during her first dental visit.


Negative reinforcement


Involves the withdrawal of an unpleasant stimulus after
a response.

 Leads to the removal of an undesirable stimulus.

Temper tantrum




Child

Go to clinic.

If this behavior (response) succeeds -- likely to occur
the next time a visit to the clinic is proposed.

 So in dental office, it is important to reinforce only desired

behavior.

Omission (also called time-out):


Involves removal of a pleasant stimulus after a
particular response.



Favorite toy taken away for a short time
(sending the mother out of the operatory) as a
consequence of this behavior, the probability of
similar misbehavior is decreased.


Punishment:
 Occurs when an unpleasant stimulus is
presented after a response. This also decreases

the probability that the behavior .
Effective at all ages, not just with children.
Firm voice – voice control.

Use of tongue crib for correction of tongue
thrusting habit.

Social Learning Theory
 Albert Bandura
 Emphasizes the importance of observing and
modeling the behaviors, attitudes, and emotional
reactions of others.
 Social learning theory explains human behavior
in terms of continuous reciprocal interaction
between cognitive, behavioral, an environmental
influences.


 General principles of social learning theory are as

follows:
1. People can learn by observing the behavior of others
and the outcomes of those behaviors.
2. Learning can occur without a change in behavior.

3. Cognition plays a role in learning.
4. Social learning theory can be considered a bridge or a
transition between behaviorist learning theories and
cognitive learning theories.


 Observational learning is also known as
Imitation or Modeling.
 Learning occurs when individuals observes and
imitate others’ behavior.
 There are four component processes influenced

by the observer’s behavior following exposure to
models.
 Attention
 Retention
 Motor Reproduction
 Motivation.

EFFECTS OF MODELING ON
BEHAVIOR
 Modeling teaches new behaviors.
 Modeling influences the frequency of previously

learned behaviors.
 Modeling may encourage previously forbidden

behaviors.
 Modeling increases the frequency of similar

behaviors.

Hierarchy Of Needs
 Maslow believed in self-actualization theory.
 Based on totality of personality development.

 But its difficult and impractical to apply to children

and dental situation.


Hierarchy Of Needs- 1954
 Abraham Harold Maslow

To achieve one’s full potential

To be competent and recognized

To love and to be loved, to have
friends
Security, comfort, freedom
from fear
Food , water and oxygen


Emotional development
 EMOTION is a state of mental excitement characterized

by physiological, behavioral changes and alterations of
feelings
Characteristics of commonly seen emotions in child
 CRY
 ANGER
 FEAR
 ANXIETY
 PHOBIA


CRY:
 Elsbach 1963

TYPES
 Obstinate cry
 Frightened cry
 Hurt cry
 Compensatory cry


OBSTINATE CRY

 Temper tantrum
 Loud, High-pitched, Siren-like

 Form of emotionally aggressive behavior
 External response to anxiety
FRIGHTENED CRY
 Torrent of tears
 Convulsive breath-catching sobs
 Situationally Over-whelmed


HURT CRY
 May be loud or a small whimper
 Single tear – First indicator
 Most easily recognized as the child
acknowledges it.
COMPENSATORY CRY
 More sound & less cry..!
 Droning monotonous coping resort
 More strategic and less anxiety related
 Few actual tears..if any..

ANGER: Outburst of emotion caused by child’s lack of
skill in handling situation.
ANXIETY: Its emotion similar to fear but arising
without any objective source of danger.(Its reaction
to unknown danger)

FEAR: Fear is reaction to known danger , its source is
consciousness.
PHOBIA: it’s a persistent , excessive ,unreasonable
fear of a specific object, activity or situation .

Behavior: any change observed
in functioning of an organism.
Frankel’s classification(1962):
1. Def –ve (- -) : refuses, cries, associated with
fear
2. – ve (-)
: reluctant and slight negativism
3. + ve (+)
: accepts, bad experience –
uncooperative
4. Def +ve (+ +): unique , looks forward,
understands importance of
treatment

Reaction to the first dental visit
 Major Hurdles..
 Fear of separation
 Maternal Anxiety
 Child’s dental awareness
 Negative portrayal of dentistry
 Age - Poor cognitive ability
 Low socioeconomic status


PSYCHOLOGICAL MANAGEMENT
 Orthodontic treatment initiated during pre-pubertal

or early pubertal developmental period of child.
 Initial exam and consultation diagnosis and

treatment plan discussed with child and parents.
 If extractions are planned, its important to present

possibility of extractions to the patient during initial
examination or early treatment planning.

Norton et al “Psychological management of young
orthodontic patient”. Angle orthodontist july 1971

PSYCHOLOGICAL MANAGEMENT OF
PATIENT BY SPECIFIC AGE GROUPS

1. YOUNG CHILD FROM 6-9YRS

 Attempt to break infantile habits of digit sucking
and tongue thrusting.
 Fixed appliances


2. EARLY ADOLESCENT ( 10-13 YRS)
 Sexual differences become more important in girl

child.
 A boy will look for male identification.

 Develops interests in sports.
 To gain co-operation from child one must show

interest in his interests.


 Explain each treatment procedure.
 If you show care for young patient , he will care for

you being co-operative.
 Female child of 10-13yrs quite different from boys.

 She is giggly, silly, extremely vain and passionately

interested in her developing body.

 Some times it may end up with CRUSH

SYNDROME– which is difficult management
problem.
 This behavior must be discouraged, but bluntness

will hurt child psychologically.
 Substitute reality for fantasy, remain cordial and

friendly talk about real world


3. TEENAGER( 14-18YRS)
 Teenage male wishes to be treated as adult.
 Management of teenage male is a matter of

sympathy and understanding.
 Teenage female has same psychic development but

different expressions.
 She is body, peer and sex conscious also, she wants

to be well developed as her peers.

MOTIVATION AND CO-OPERATION
 Patient cooperation is an essential factor in the

timely, successful outcome of orthodontic treatment.

 Parents of orthodontic treatment undergoing

child more motivated than parents of those
children are not yet in treatment
Daniels et al Orthodontic treatment motivation and cooperation: A
cross-sectional analysis of adolescent patients’ and parents’
responses. , Am J Orthod Dentofacial Orthop 2009;136:780-7)

 Girls reported greater willingness to cooperate with

orthodontic treatment than did boys.
 Furthermore, mothers reported that their children

would be more cooperative with treatment than did
the fathers.
 Mothers were also more motivated for their child to

have braces than were fathers.


PATIENT COMPLIANCE AND
ORTHODONTIC TREATMENT
 Patient psychology and compliance are important

factors in the treatment protocol. Patient compliance
appears to be a complex issue that cannot easily
be predicted before treatment .
 There is an incidental psychological gain through

orthodontic treatment.
 Shin-Jae Lee et al “ Patient compliance and locus of control in

orthodontic treatment: A prospective study”
Am J Orthod Dentofacial Orthop 2008;133:354-8)

 Compliance is not related to patient satisfaction in the

long run.
 Sex is a significant predictor for patient satisfaction

regarding the doctor-patient relationship and the
situational aspects of the treatment.
 Treatment time for female subjects would be longer than

for male subjects, even though actual treatment time
showed no differences.
 Annemieke bos et al Patient compliance: A determinant of

patient satisfaction?
Angle orthod 2005; 75:526–531


Effect of behavior modification on patient
compliance in orthodontics.
David Richeter et al , Angle Orthod 1998,68(2)
123-132
 Study the effects of reward system for improving

patient compliance.
 Above average compliance group remained

unchanged.
 Below average improved with rewards , however

never reached above average.
 Age and sex – no influence.

CONCLUSION
Old men can make war, but it is
children who will make history.


REFERENCES
 Contemporary Of Orthodontics- William R Proffit.
 Textbook Of Pedodontics -- Shoba Tendon
 Essentials Of Preventive And Community Dentistry – Soben

Peter
 Norton et al “Psychological management of young orthodontic

patient”. Angle orthodontist july 1971

 Daniels et al Orthodontic treatment motivation and

cooperation: A cross-sectional analysis of adolescent patients’
and parents’ responses. , Am J Orthod Dentofacial Orthop
2009;136:780-7)

 Shin-Jae Lee et al “ Patient compliance and locus of

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 Annemieke bos et al Patient compliance: A determinant

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 David Richeter et al Effect of behavior modification on

patient compliance in orthodontics. Angle Orthod
1998,68(2) 123-132

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