child psychology and its relevance in orthodontics

1. CHILD PSYCHOLOGY
MOHAMED RAMEEZ

2. CONTENTS
 INTRODUCTION
 DEFINITIONS
 THEORIES OF PSYCHOLOGICAL DEVELOPMENT
 PSYCHODYNAMIC THEORIES
 BEHAVIOUR LEARNING THEORIES
 MANAGING A CHILD
 PSYCHOSOCIAL ASPECTS IN ORTHODONTIC TREATMENT
 ORTHODONTIC TREATMENT FOR SPECIAL NEEDS CHILD
 CONCLUSION
 REFERENCES
 ACKNOWLEDGEMENT

3. INTRODUCTION
Thousands and thousands of young people are receiving orthodontic
attention in this country constantly. It is true that some are under
treatment only for comparatively short periods, while others require
treatment during a period of several years.
One of our big problems is to get these young people to
enjoy coming to our office, and in order to do this in many instances
it is necessary to study their likes and dislikes, so that we may better
understand their thoughts.

4. Definition
 Psychology can be defined as ‘Science dealing with
human nature, function and phenomenon of his soul in
the main’.
 Child psychology is the science or study of child’s mind
and how it functions .It deals with the mental power or
an interaction between the conscious and subconscious
elements in a child.

5. Classification of psychological developmental
theories
Psychodynamic Theories:
 Psychoanalytical Theory –Sigmund Freud
 Psychosocial Theory-Eric Erickson
 Cognitive Theory- Jean Piaget
Behavioural Learning Theories:
 Social Learning Theory-Albert Bandura
 Classical Conditioning Theory-Ivan Pavlov
 Operant Conditioning Theory-Skinner

6. Psychoanalytical theory
 Coined by Sigmund freud,1905
 Austrian neurologist and the founder of
psychoanalysis.
 Two primary ideas of Freud's theory:
1. Everything you become is determined by
your first few years
2. The story of development is the story of
how to handle anti-social impulses in
socially acceptable ways

7. Psychic triad
 Freud has explained behaviour based on 3 components
ID
EGO
SUPER EGO

8. ID
 Present since birth.
 It is governed by pleasure principle.
 Its an instinctual drive or energy to meet bodily needs and
desires.
 Examples: hunger, thirst, aggression, sexual drive etc..
 These drives are necessary for survival of species.
 Ego and super ego control or mediate id.
 If id is superior over ego and super ego the person tends to be
selfish and inconsiderate.

9. EGO
 Mediator between id and super ego
 Its involves functions such as memory, language, intelligence and
creativity
 Maintains adequate expression of id within the constraints of
superego
 Gives the mind a reality check
 If ego superimposes super ego, restrictions set by super ego will
be weak leading to a possible unsocialized behaviour

10. SUPER EGO
 Similar to social conscience
 Derived from familial and cultural restrictions placed upon the
growing child
 Super ego consists of all moral lessons learned from life
 If super ego is superior to id and ego the person will be extremely
considerate to others.

13. Phases of development based on
Id, Ego, Super ego
Oral stage
Anal stage
Urethral stage
Phallic stage
Latency stage
Genital stage

14. Oral stage (0-1 year)
 Occurs from birth till one year
 The infant’s primary source of interaction occurs through the
mouth, so the rooting and sucking reflex is especially important.
 The oral cavity therefore serves as an erogenous zone.
 The mouth is vital for eating, and the infant derives pleasure from
oral stimulation through gratifying activities such as tasting and
sucking.
 Because the infant is entirely dependent upon caretakers, the
infant also develops a sense of trust.

15. Anal stage (1-3 years)
 During this stage , maturation of neuromuscular control occurs
on bladder and bowel movements.
 The major conflict at this stage is toilet training, the child has to
learn to control his or her bodily needs.
 Developing this control leads to a sense of accomplishment and
independence.
 Failure in this stage is characterised by various abnormal
behaviours like –disorderliness , untidiness, stubbornness,
destructiveness.

16. Phallic stage (3-6 years)
 The primary focus of the libido is on the genitals.
 Children discover the differences between males and
females.
 There is an increasing awareness of sex roles and
emerging interest in the parent of opposite sex.
 Freud called this Oedipus complex in boys and Electra
complex in girls

17.  Oedepus complex
It is the tendency of young boy child being attached more
to the mother than the father.
 Electra complex
It is the tendency of the young girl child developing an
attraction towards father.

18. Latency stage(7-12 years)
 During the latent period, the libido interests are suppressed.
 The stage begins around the time that children enter into school
and become more concerned with peer relationships, hobbies,
and other interests.
 The latent period is a time of exploration in which the sexual
energy is still present, but it is directed into other areas such as
intellectual pursuits and social interactions.
 This stage is important in the development of social and
communication skills and self-confidence.
 This results in maturation of ego and mastery over skills.

19. Genital stage (12- young adult)
 During the final stage of psychosexual development, sense of
identity develops.
 Disturbance in this stage result in :
the individual cannot reach maturity, cannot shift the focus from
their own body, their own parents and their immediate needs to
larger responsibilities involving others

20. Psychosocial theory
Erickson is a Freudian ego-psychologist.
He accepts Freud's ideas as basically correct,
including the more debatable ideas such as the
Oedipal complex, and the ideas about the ego.
He believed in eight stages which are great
struggles people must undergo

21. The epigenetic theory
 This principle says that we develop through a predetermined
unfolding of our personalities in eight stages.
 Our progress through each stage is in part determined by our
success, or lack of success

22.  A malignancy involves too little of the positive and too
much of the negative aspect of the task.
 A maladaptation involves too much of the positive and
too little of the negative

24. The first stage - oral-sensory stage (first year
of life)
 Trust vs mistrust
 Basic needs are met by person whom he trusts
 When needs are not met it leads to mistrust
 Hope and danger- a child with mistrust can gain trust by
developing hope

27. Second stage (2-3 years)
 Autonomy vs Doubt
 If mom and dad , permits the child, to explore and
manipulate his or her environment, the child will
develop a sense of autonomy or independence.
 Failure to do so will make the child doubt their abilities

28. Third stage (4-5 years)
 Initiative vs guilt
 Initiative means a positive response to the world's challenges,
taking on responsibilities, learning new skills, feeling purposeful.
 Too much initiative and too little guilt means a maladaptive
tendency of ruthlessness.
 For most children ,first dental visit comes in this age of initiative.
Going to dentist come as a challenge, in which a child can
experience success .

29. Fourth stage- latency stage(6-11 years)
 Industry vs inferiority
 Industry refers to child’s involvement in situations where long
patient work is needed
 Inferiority is a feeling created when a child geta a feeling of failure
when they cannot finish or master their school work

30. Stage five- adolescence (12-18 years)
 Identity vs role confusion.
 Identity means knowing who you are and how you fit in
to the rest of society.
 Role confusion, meaning an uncertainty about one's
place in society and the world
 The transition from childhood to adulthood

31.  Most orthodontic treatment is carried out during the adolescent
years, and behavioral management of adolescents can be
extremely challenging.
 A poor psychological situation is created by orthodontic
treatment if it is being carried out primarily because the parents
want it, not the child.
 At this stage, orthodontic treatment should be instituted only if
the patient wants it, not just to please the parents.

32. Stage of adulthood (18-30 years)
 Intimacy vs isolation
 Intimacy is the ability to be close to others, as friend, and as a
participant in society .
 The maladaptive form causes tendency to become intimate too
freely, too easily, and without any depth .
 The malignancy is exclusion ,refers to the tendency to isolate
oneself from love, friendship, and community, and to develop a
certain hatefulness in compensation for one's loneliness.

33.  A growing number of young adults are seeking orthodontic care.
Often these individuals are seeking to correct a dental
appearance they perceive as flawed. They may feel that a change
in their appearance will facilitate attainment of intimate
relationships.
 On the other hand, a "new look" resulting from orthodontic
treatment may interfere with previously established relationships.

34. Stage seven - middle adulthood (middle
twenties to the late fifties)
 The task here is to cultivate the proper balance of generativity and
stagnation.
 Generativity is an extension of love into the future. It is a concern for
the next generation.
 Stagnation, on the other hand, is self absorption, caring for no one.
 The stagnant person ceases to be a productive member of society.
 The maladaptive tendency is termed as overextension . Some people
try to be so generative that they no longer allow time for themselves,
for rest and relaxation.

35. Stage eight - late adulthood ( as old age)
 The task is to develop ego integrity with a minimal amount of despair.
 Despair- some older people become preoccupied with their past.
They think, that's where the things were better. Become preoccupied
with their failures, bad decisions and regret them.
 Integrity means coming to terms with your life, and thereby coming to
terms with the end of life. If they are able to look back and accept the
course of events, the choices made, the life as they lived it, as being
necessary, then they don`t fear death.

36. Cognitive theory
 Jean piaget,1952
 Process of cognitive development: every
individual is born with the capacity to
adjust and adapt to both physical and
sociocultural environment in which he or
she live in.
 He described two processes used by the
individual in its attempt to adapt:
assimilation and accommodation.

37.  Assimilation is the process of incorporation of events within
environment into mental categories called cognitive structures or
schemas
 Accommodation is the process of changing cognitive structures to
better represent the environment. Both processes are used
simultaneously and alternately throughout life.
 Equilibration Refers to changing basic assumptions following
adjustments in assimilated knowledge so that the facts fit better.

40. stage two
 A major feature of this stage is
ego centrism and animism.
Ego centrism – The child is
incapable of assuming another
persons point of view.
Animism – Everything is seen as
being alive.

41. Piaget’s mountain task

43. Concrete operation period (7-11 years)
 Concrete operations develop based on the level of
understanding achieved so far.
 The thinking process becomes logical
 Child develops the ability to use complex mental
operations such as addition and subtraction.

44.  The child is able to understand others point of view.
 Children in this period are much more like adults in the
way they view the world but they are still cognitively
different from adults.
 Presenting ideas as abstract concepts rather than
illustrating them with concrete objects can be a major
barrier to communication.

45. Formal operations stage(12 years to adult)
 The child’s thinking process becomes like adult.
 He thinks of ideas and has developed a vast imagination
 This involves using logical operations, and using them in
the abstract, rather than the concrete. We call this as
hypothetical thinking.

46.  A new expression of egocentrism develops , they
presume that they and others are thinking about the
same thing. They feel as though they are constantly "on
stage," being observed and criticized by those around
them. This phenomenon has been called as the
"imaginary audience".

47. Psychodynamic Theories:
 Psychoanalytical Theory –Sigmund Freud
 Psychosocial Theory-Eric Erickson
 Cognitive Theory- Jean Piaget
Behavioural Learning Theories:
 Social Learning Theory-Albert Bandura
 Classical Conditioning Theory-Ivan Pavlov
 Operant Conditioning Theory-Skinner

48. Classic conditioning-Ivan Pavlov(1927)
 Ivan Petrovich Pavlov was a Russian
physiologist known primarily for his
work in classical conditioning.
 The theory is a result of classic
experiments which are called
respondent conditioning or pavlovian
conditioning

49.  Classical conditioning operates by the simple process of
association of a stimulus with another also called as
learning by association

52.  A child, by his previous bad experience with a dentist on
white coat will associate the pain of injection to our
white coat and become fearful and starts crying because
of association of stimulus.

53. Operant conditioning theory
 Burrhus Frederic Skinner, commonly known
as B. F. Skinner, was an American
psychologist, behaviourist, author, inventor,
and social philosopher
 According to this theory, the consequences
of behaviour itself act as a stimulus and
affects future behaviour.
 Skinner described 4 basic types of operant
conditioning distinguished by the type of
consequences

54.  Positive reinforcement :Occurs if a pleasant consequence follows the
response.
 For example if we dentists reward our child patients during their first
visit for being well, we can expect a positive response next time also.
 Negative reinforcement : It involves removal of unpleasant stimuli
following a response.
 Eg :if the child shows temper tantrums during his first visit and become
successful , during the next visit also he repeats it, since this behaviour
have become negatively reinforced . So it is our duty to reinforce only
desired behaviour and is equally important to avoid reinforcing
behaviour that is not desired.

55.  Omission Involves removal of a pleasant stimulus after a particular
response.
 Example: if the child misbehaves during the dental procedure, his
favourite toy is taken away for a short time, resulting in the omission of
the undesirable behaviour.
 Punishment : Introduction of an aversive stimulus into a situation to
decrease the undesirable behaviour.

59. Social learning theory
 Albert bandura,1963
 He suggested that environment causes
behaviour and behaviour causes
environment .
 The world and a persons behaviour
cause each other.
 He called this concept as reciprocal
determinism.

64. Topics to be covered in next session
 MANAGING A CHILD
 PSYCHOSOCIAL ASPECTS IN ORTHODONTIC TREATMENT
 ORTHODONTIC TREATMENT FOR SPECIAL NEEDS CHILD
 CONCLUSION
 REFERENCES
 ACKNOWLEDGEMENT

65. Thankyou

66. CHILD PSYCHOLOGY
SECOND SESSION

67. Previous session
 INTRODUCTION
 DEFINITIONS
 PSYCHODYNAMIC THEORIES:
 PSYCHOANALYTICAL THEORY –SIGMUND FREUD
 PSYCHOSOCIAL THEORY-ERIC ERICKSON
 COGNITIVE THEORY- JEAN PIAGET
 BEHAVIOURAL LEARNING THEORIES:
 SOCIAL LEARNING THEORY-ALBERT BANDURA
 CLASSICAL CONDITIONING THEORY-IVAN PAVLOV
 OPERANT CONDITIONING THEORY-SKINNER

68. Second session
 MANAGING A CHILD
 PSYCHOSOCIAL ASPECTS IN ORTHODONTIC TREATMENT
 ORTHODONTIC TREATMENT FOR SPECIAL NEEDS CHILD
 CONCLUSION
 REFERENCES
 ACKNOWLEDGEMENT

69. Managing a child
 Most orthodontic treatment
initiated during pre pubertal
or early pubertal period 1
 Orthodontists are able to
bring about an aesthetic as
well as functional
improvement for his patients
2

70.  The behavioural sciences have played a significant role
in orthodontics
 The majority of orthodontic patients who seek care
under their own initiative (adult patients) do so to
improve their facial appearance.
 When the mothers of adolescents are asked, most
respond that they want their children to look better.

71. Young child (6 to 9 years)
 Easiest to work with.
 Same approach for both boys and girls.
 Natural curiosity of school days makes their attention readily
available.
 The best method for obtaining cooperation is to actively teach the
child the purpose of treatment.
 Children of this age are natural imitators. They tend to do almost
anything they are told to do, particularly if it is with precise
directions.

72.  It is difficult to use removable appliances in children from six to
nine because of the following reasons
 In the early mixed dentition when undercut areas for
appliance retention are hard to find.
 They are learning to articulate adult speech patterns.
 They are attempting to break their infantile habits of digital
sucking and tongue thrusting.
Psychologic management of orthodontic patients-AO July 1971

73. Early Adolescent (10-13years) : Boys
 Retains his curiosity about the "why" of treatment during this
period, but “how” captures his imagination
 The procedure should be explained to the boy
 To gain boy’s attention we should know about their interests
 Allow the child to observe operative procedures through a hand
mirror.
 Allow him to hold some materials such as blunt hand
instruments, wax, alginate.

74. Early adolescent(10-13 years): girls
 Quite different from the boy but an equal challenge.
 Any dental procedure that might affect her looks is either
accepted with excitement or fear.
 The conversation should be brief, pleasant, impersonal and
thoughtful
 Crush syndrome is a management problem at this age

75. The Teenage (14-18years) :Male
 He wishes to be treated as an adult but often express
himself as an irrational child .
 Management of the teenage male is a matter of
sympathy and understanding.
 One must be direct and forthright.

76. The Teenage (14-18years) :female
 She is conscious about her appearance and peers .She wants to
be as proportional as her peers.
 Orthodontic appliances offer a threat to her image or, if she has
an unesthetic malocclusion.
 Once trust is established, she will usually be cooperative.
 Latent crush syndromes can occur in this age group, particularly in
girl with the unaesthetic malocclusion.

77. Psychosocial aspects in orthodontics
 Many patients seek orthodontic care to
improve that quality of life.
 They found facially disfigured people, such as
orthodontic patients with significant skeletal
discrepancies had a more difficult time in
school, and also they were less to well in
employment, politics or advertising.
 Clearly, a person’s dentofacial appearance can
have significant effect on their quality of life.

78. Psychosocial impact of malocclusion
 Malocclusion has been broadly defined as physical deviations
from ideal occlusal relations.
 Malocclusions are often differentiated from more severe forms of
dentofacial malrelations such as cleft lip and palate or severe
facial injury.
 The impact of malocclusion on psychosocial factors can be
understood in the context of two interrelated processes.
 The first deals with social judgement and responses of others
to malocclusion.
 The second process involves patients' self adjustment to
malocclusion.

79. Social Judgements of Malocclusion
 Dental characteristics are fundamental determinants of facial
appearance, an important factor in personal identification and
nonverbal communication.
 There is reason to believe that specific facial deviations, including
malocclusion, give rise to similar social stereotypes

80. Self-Adjustment to Malocclusion
 Patients with malocclusion may develop different coping
mechanisms as a defence against negative social judgement.
 More severe forms of facial malformation may have greater
adverse effects on self-image than does malocclusion.

81. Psychosocial Effects of Treatment- Patient Expectations
 Improved aesthetics and function
 There is also evidence that patients expect certain psychosocial
benefits after treatment. In an
 Wictorin et al reported that 60% of patients believed that self-
confidence would increase in relation to the opposite sex, and
54% believed they would be happier if their malocclusion was
corrected.

82. Psychological outcomes of orthodontic
treatment:
 Albino showed the psychological and
social effects of orthodontic treatment
 Children who received orthodontic
treatment felt better about their facial
appearance after braces than they did
before them

83. Orthodontic treatment timings
 There is an on-going debate pertaining to ideal time for
orthodontic treatment.
 Case selection based upon severity and type of malocclusion is an
important factor .
 Burns 21 has mentioned the inadequacy of instructions in
handling patients.
 He notes that “no general set of suggestions is applicable for
handling patients as a group, since they show wide variation in
physical development, emotional maturity, social experiences,
attitude towards authority and ability to accept responsibility”.

84. Motivational psychology
 Patient compliance is the prime “mantra” of successful
orthodontic treatment.
 Headgear effects, functional appliances treatment, oral hygiene
and keeping appointments are all dependent upon patient
complying with the doctor’s instructions.
 Egolf described a compliant patient as one who practices good
oral hygiene, wears appliances as instructed without abusing
them, follows an appropriate diet and keeps appointments.

85.  Adults are generally compliant patients but adolescents are generally in the
orthodontist’s office because a part has brought them there and their goals
for treatment are frequently non-specific.
 Southard et al pointed out that the assurance of good compliance can be
difficult in case of adolescent.
 Compliance by the patient helps achieve treatment objectives in a minimum
treatment time and improved co-operation of the patient can also reduce
expenses of orthodontic treatment.
 According to Nanda, Sinha, the efficiency of care and improved oral hygiene
can decrease damage to periodontal tissues and limit effects of enamel
decalcification and caries

86. Orthodontic treatment for the special needs
child

87. First Dental Visit
 Initial dental examination.
 Establish an excellent relationship with the parents, guardian and
the patient.
 Through medical & dental history.
 We must be prepared to discuss the patient health status &
possible planned dental treatments with the physicians.

88. Common oral & dental problems
 Gingivitis & periodontitis.
 Caries lesions
 Poor oral hygiene
 drugs used causes salivation .
 Malocclusion.
 Dental abrasions.
 Para functional habits
(Bruxism)

89. At the time of treatment we must consider factors such as :
 The level of dependency
 Type of disability.
 Associated systemic disease.
 Effects of medications.
 Level of oral hygiene.
 Malocclusion.

90.  General behaviour is often problematic because of
reduced understanding and increased apprehension,
short attention span, and limited tolerance.
 Uncontrolled limb and head movements and an inability
to sit still—making it difficult even to seat the child in
the dental chair.

91.  Level of cooperation during treatment is usually
significantly impaired.
 Exaggerated gag reflex, apparently related to
dental/medical phobia
 Markedly increased incidence of drooling in many cases

92. Conclusion
 Child psychology is one of the very important questions for
consideration by the orthodontist, if he expects to meet with the
best success in his practice.
 In conclusion, while the literature on the subject of child
psychology is extensive and much of it worth reading, Plato over
two thousand years ago made a brief statement, which is just as
appropriate today as at that time when he said: “The best way of
training the young is to train yourself at the same time; not to
admonish them, but to be always carrying out your principles in
practice.”

93. References
 Moyers Robert E.: Hand book of Orthodontics. Year book Medical publishers, Inc, 198;
4th Edition.
 Bishara Samir E.: Text book of Orthodontics. Saunders 2003.456-462.
 Proffit W R: Contemporary Orthodontics. Mosby 2000.5th Edition.50-65.
 Amanpreet Kaur Grewal, James Sunny P, Valiathan A. Expectations and perceptions of
patients towards orthodontic treatment in Manipal . J Pierre Fauchard Academy
2003;19:83-88.
 Sachdeva Sunil & Valiathan Ashima: "Whose mouth is it anyway?". Journal of Indian
Orthodontic Society, 1994; 22(3): 105-108.

94. References
 Sunil Sachdeva & Valiathan Ashima: Co-operation in orthodontics. Nepal Dental Journal 1999
:2(1)21-26.
 Irfan & Valiathan Ashima Dawoodbhoy, : Age & Orthodontics. Journal of International College
of Dentist. 1993; 34: 20-25
 Ravinder V.& Ashima Valiathan. Psychology in Orthodontics. Kerala Dent J,2006; 29(2): 41-43.
 Louis A. Mark Markowitz. Psychological management of orthodontic patient: A O.July
1971;41(3):241-248.
 M M Gershater.The psychologic dimension of orthodontic diagnosis and treatment
.AJODO,1968;54(5); 327-338.
 Dale.H.Schunk. Learning theories-An educational Perspective.2000 ;4th ed. Merrill Prentice
Hall.

95. References
 E.B.Hurlock. Developmental Psychology-A life span approach .1981;5th ed .Tata McGraw
Hill.
 John .B. Best. Cognitive psychology ;5th ed .1998;International Thombson Publishing
Company.
 Paul Henry Mussen. Child development and personality; 1984.6th ed ;Harper and row N.Y.
 Barbara L. Chadwick .Child taming-how to manage children in dental practice.
2003;Quintessence Publication.
 Pinkham .Pediateric Dentistry; 4th ed 2005.Elsevier.
 McDonald. Dentistry for the child and adolescent .8th ed .2004;Elsevier
 Jay Weiss. Psychological timing of orthodontic treatment .AJO 1977:72.2.198-203

96. ACKNOWLEDGEMENT
 DR. RAJKUMAR. S.ALLE
 DR. SHWETHA.G.S
 DR. SHASHI KUMAR.H.C
 DR. SUMA.T
 DR. LOKESH.N.K
 DR. KIRAN.H
 DR. SIDHARTH ARYA
 DR. DHARMESH.H.S
 DR.BHARATI
 DR.FAISAL ARSHAD

97. Thankyou