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Child psychology /certified fixed orthodontic courses by Indian dental academy


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Child psychology /certified fixed orthodontic courses by Indian dental academy

  2. 2. CHILD PSYCHOLOGY INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. • • • • • • • • • • • Contents Introduction Classification of basic theories Psychosexual Theory Psychosocial Theory Cognitive Theory Social Learning Theory Classical Learning Theory Operant Conditioning Theory Child Management Conclusion References
  4. 4. INTRODUCTION "At first glance, the disciplines of psychology and clinical orthodontics would seem to be as separate as any two disciplines one could find. It has been stated that 'One is mental, the other is dental'. Indeed, it is difficult to bring these two sciences together. One involves clinical treatment; the other is a social science. The clinician measures physical characteristics with direct precision in terms of millimeters and degrees; the psychologist measures less specific entities, such as verbal social actions and attitudes. Yet while these two sciences appear to be dichotomous, there are areas of overlap where interdisciplinary considerations are both useful and necessary." Dr T.M. Graber .
  5. 5. Classification of psychological developmental theories • Psychodynamic Theories: • Psychosexual Theory –Sigmund Freud • Psychosocial Theory-Eric Erickson • Cognitive Theory- Jean Piaget • Behavioral Learning Theories: • Social Learning Theory-Albert Bandura • Classical Conditioning Theory-Ivan Pavlov • Operant Conditioning Theory-Skinner
  6. 6. Psychosexual Theory-Dr. Sigmund Freud(1905)
  7. 7. • What is Psychosexual Development? • According to Freud, personality is mostly established by the age of five. Early experiences play a large role in personality development and continue to influence behavior later in life. Freud believed that personality develops through a series of childhood stages during which the pleasure seeking energies of the id become focused on certain erogenous areas. These psychosexual energies, or libido, were described as the driving force behind behavior.
  8. 8. • The Structural Model of Personality: • According to Freud’s psychoanalytic theory of personality, personality is composed of three elements. These three elements of personality are known as the id, the ego, and the superego which work together to create complex human behaviors.
  9. 9. • The Id • The id is the only component of personality that is present from birth • This aspect of personality is entirely unconscious and includes of the instinctive and primitive behaviors. • Id is the source of all psychic energy, making it the primary component of personality. • The id is driven by the pleasure principle, which strives for immediate gratification of all desires, and needs. If these needs are not satisfied immediately, the result is a state anxiety or tension.
  10. 10. • Behavior ruled entirely by the pleasure principle can be both disruptive and socially unacceptable. • The id tries to resolve the tension created by the pleasure principle through the primary process, which involves forming a mental image of the desired object as a way of satisfying the need.
  11. 11. • The Ego • The ego is the component of personality that is responsible for dealing with reality. • Ego develops from the id and ensures that the impulses of the id can be expressed in a manner acceptable in the real world. The ego functions in the conscious, preconscious, and unconscious mind. • The ego operates based on the reality principle, which strives to satisfy the id’s desires in realistic and socially appropriate ways.
  12. 12. • In many cases, the id’s impulses can be satisfied through a process of delayed gratification—the ego will eventually allow the behavior, but only in the appropriate time and place. The ego also discharges tension created by unmet impulses through the secondary process, in which the ego tries to find an object in the real world that matches the mental image created by the id’s primary process.
  13. 13. • The Superego Is the aspect of personality that holds all of our internalized moral standards and ideals that we acquire from both parents and society-our sense of right and wrong. The superego provides guidelines for making judgments. The superego begins to emerge at around age five. Has two parts: • The ego ideal -includes the rules and standards for good behaviors. These behaviors include those which are approved of by parental and other authority figures. Obeying these rules leads to feelings of pride, value, and accomplishment.
  14. 14. • The conscience- includes information about things that are viewed as bad by parents and society. These behaviors are often lead to bad consequences, or feelings of guilt. • The superego acts to perfect and civilize our behavior. It works to suppress all unacceptable urges of the id and struggles to make the ego act upon idealistic standards rather that upon realistic principles. The superego is present in the conscious, preconscious, and unconscious mind.
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  16. 16. • The Interaction of the Id, Ego, and Superego With so many competing forces, it is easy to see how conflict might arise between the id, ego, and superego. Freud used the term ego strength to refer to the ego’s ability to function despite these dueling forces. A person with good ego strength is able to effectively manage these pressures, while those with too much or too little ego strength can become too unyielding or too disrupting. According to Freud, the key to a healthy personality is a balance between the id, the ego, and the superego.
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  18. 18. Stages of psychosexual development • The Oral Stage (0 to 1 yr ) • The infant’s primary source of interaction occurs through the mouth, so the rooting and sucking reflex is especially important. 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 and comfort through this oral stimulation. • The primary conflict at this stage is the weaning process the child must become less dependent upon caretakers.
  19. 19. If a person has difficulties in the tasks associated with the stage - weaning – he will tend to retain certain infantile habits. This is called fixation. Fixation gives problem at each stage and a long term effect in terms of our personality • If a child is frustrated in his need to suckle, then he may develop an oral-passive character. An oralpassive personality tends to be dependent on others. They often retain an interest in "oral gratifications" such as eating, drinking, and smoking. It is as if they were seeking the pleasures they missed in infancy.
  20. 20. • When child is between five and eight months of age , he begin teething. One satisfying thing to do when teething is to bite on something. If this causes a great deal of upset to the mother and precipitates an early weaning, person may develop an oralaggressive personality. These people retain a lifelong desire to bite on things, such as pencils, gum, and other people. They have a tendency to be verbally aggressive, argumentative & sarcastic.
  21. 21. • The Anal Stage (2 to 3 yr) • The primary focus of the libido is on controlling 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. • Success at this stage is dependent upon the parents approach to toilet training. • If parents take an approach that is too lenient, an analexpulsive personality can develop in which the individual has a messy, wasteful, or destructive personality. • If parents are too strict or begin toilet training too early, an anal retentive personality develops in which the individual is stringent, orderly, rigid, and obsessive.
  22. 22. • The Phallic Stage (3 to 7 yr) • The primary focus of the libido is on the genitals. Children discover the differences between males and females. • Boys begin to view their fathers as a rival for the mother’s affections. The Oedipus complex describes these feelings of wanting to possess the mother and the desire to replace the father. However, the child also fears that he will be punished by the father for these feelings, a fear Freud termed castration anxiety. The term Electra complex has been used to described a similar set of feelings experienced by young girls.
  23. 23. • The Latent Period (8 to 11 yr) • During the latent period, the libido interests are suppressed. The development of the ego and superego contribute to this period of calm. 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.
  24. 24. • The Genital Stage (12 yrs to adult) • During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. Where in earlier stages the focus was solely on individual needs and, interest in the welfare of others grow during this stage. • If the other stages have been completed successfully, the individual should now be well balanced, warm, and caring. The goal of this stage is to establish a balance between the various life areas.
  25. 25. Psychosocial Theory-Eric Erickson(1963) • Erikson is a Freudian egopsychologist. He accepts Freud's ideas as basically correct, including the more debatable ideas such as the Oedipal complex, and the ideas about the ego. However, Erikson is much more society and cultureoriented than Freud.
  26. 26. The epigenetic principle 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, in all the previous stages. • Each stage involves certain developmental tasks. • The various tasks are referred to by two terms . • Each stage has a certain optimal time as well.
  27. 27. • If a stage is managed well, we carry away a certain virtue or psychosocial strength which will help us through the rest of the stages of our lives. If we don't, we may develop: maladaptations and malignancies. • 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
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  29. 29. The first stage - oral-sensory stage, (Birth to 1- 1/2 yr) The task is to develop trust without completely eliminating the capacity for mistrust. • If mom and dad can give the newborn a degree of familiarity, consistency, then the child will develop the feeling that the world is a safe place to be and learns to trust his or her own body and the biological urges that go with it. • If the parents are unreliable and inadequate, if they reject the infant , then the infant will develop mistrust. He or she will be apprehensive and suspicious about people. • Parents who are overly protective of the child, are there the minute the first cry comes out, will lead that child into the maladaptive tendency of sensory maladjustment.
  30. 30. • Worse, is the child whose balance is tipped way over on the mistrust side, they develop the malignant tendency of withdrawal, characterized by depression and possibly psychosis. • If the proper balance is achieved, the child will develop the virtue hope, the strong belief that, even when things are not going well, they will work out well in the end.
  31. 31. • The tight bond between parent and child ,in this early stage of emotional development is reflected as strong sense of "separation anxiety" in the child when separated from his parent. If it is necessary to provide dental treatment at an early age, it usually is preferable to do so with the parent present, and if possible, while the child is being held by one of the parents. At later ages, a child who never developed a sense of basic trust will have difficulty entering into situations that require trust and confidence in another person. Such an individual is likely to be an extremely frightened and uncooperative patient who needs special effort to establish rapport and trust with the dentist and stuff.
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  33. 33. Stage two- anal-muscular stage (18 months to 4 yrs) • The task is to achieve a degree of autonomy while minimizing shame and 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. • If the parents come down hard on any attempt to explore and be independent, the child will soon give up with the assumption that cannot and should not act on their own.
  34. 34. • A little "shame and doubt" is not only inevitable, but beneficial. Without it, child will develop the maladaptive tendency called impulsiveness, a sort of shameless that leads him to jump into things without proper consideration of his abilities. • Too much shame and doubt, which leads to the malignancy of compulsiveness. The compulsive person feels that everything must be done perfectly. • If child get the proper, positive balance of autonomy and shame and doubt, he will develop the virtue of willpower or determination.
  35. 35. A key toward obtaining cooperation with treatment from a child at this stage is to have the child think that whatever the dentist wants was his or her own choice, not something required by another person. For a 2-year-old seeking autonomy, it is all right to open his mouth if he want to, but almost psychologically unacceptable to do it if someone tells him to. One way around this is to offer the child reasonable choices whenever possible, for instance, either a green or a yellow napkin for the neck.
  36. 36. • Stage three (3 -6 yrs) The task of this stage is to learn initiative without too much guilt. • Initiative means a positive response to the world's challenges, taking on responsibilities, learning new skills, feeling purposeful. Parents can encourage initiative by encouraging children to try out their ideas. • Erikson includes the Oedipal experience in this stage. Oedipal crisis involves the reluctance a child's feeling in relinquishing his or her closeness to the opposite sex parent. A parent has the responsibility, socially, to encourage the child to “grow up”. But if this process is done too harshly ,the child learns to feel guilty about his or her feelings.
  37. 37. • Too much initiative and too little guilt means a maladaptive tendency of ruthlessness. It's just that they don't care who they step on to achieve their goals. The goals are everything, and guilty feelings are for the weak. • Malignancy of too much guilt, which Erikson calls inhibition. The inhibited person will not try things because "nothing ventured, nothing lost" and, nothing to feel guilty about. A good balance leads to the psychosocial strength of courage.
  38. 38. 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 .Success in coping with this anxiety helps to develop greater independence and produce a sense of accomplishment. Poorly managed dental visit can also contribute toward the guilt that accompanies failure. A child at this stage will be intensely curious about the dentists office and eager to learn about the things found there. An exploratory visit with the mother present and with little treatment accomplished usually is important in getting the dental experience off to a good start. After the initial experience, a child at this stage can usually tolerate being separated from the mother for treatment and is likely to behave better in this arrangement, so that independence rather than dependence is reinforced.
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  45. 45. • Stage four- latency stage (6 to 12 years) • The task is to develop a capacity for industry while avoiding an excessive sense of inferiority. • The parents are joined by teachers and peers. They all contribute. Parents must encourage, teachers must care, peers must accept .They must learn the feeling of success, whether it is in school or on the playground, academic or social. • If the child is allowed too little success, because of harsh teachers or rejecting peers, then he or she will develop a sense of inferiority .
  46. 46. • Too much industry leads to the maladaptive tendency called narrow virtuosity. E.g. : child actors. We all admire their industry, but if we look a little closer, it's all that stands in the way of an empty life. • Much more common is the malignancy called inertia. This includes all of us who suffer from the "inferiority complexes" . If at first we don't succeed, we don't ever try again! We become inert. The right balance of industry and inferiority mostly industry with just a touch of inferiority to keep us sensibly humble, then we have the virtue called competency.
  47. 47. • Orthodontic treatment in this age group is likely to involve the faithful wearing of removable appliances. Whether a child will do so is determined in large part by whether he or she understands what is needed to please the dentist and parents, whether the peer group is supportive, and whether the desired behavior is reinforced by the dentist.
  48. 48. Psychological timing of orthodontic treatment-by-Jay Weiss:AJO-1977 • A questionnaire type of study was undertaken to test the hypothesis that prepubescent patients are more cooperative than adolescents. • Older children were found to be psychologically resistant to the demands of orthodontic treatment because of their involvement in Oedipal conflicts, a normal but distracting aspect of "growing up.“
  49. 49. • Study found that patients under 12 were more cooperative than other age groups in the wearing of headgear and other removable devices but they were less cooperative in keeping appointments or in protecting appliances from breakage. • The study suggests that, from a psychological standpoint, activator and headgear treatment should be begun sometime after age 6 and soon enough to be completed before the onset of puberty.
  50. 50. • Children at this stage still are not likely to be motivated by abstract concepts such as "If you wear this appliance your bite will be better." They can be motivated, however, by improved acceptance or status from the peer group. This means that emphasizing how the teeth will look better as the child cooperates is more likely to be a motivating factor than emphasizing a better dental occlusion, which the peer group is not likely to notice.
  51. 51. Stage five – adolescence ( puberty to18 or 20 years) • Ego identity and avoid role confusion. • Ego 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. An adolescent asks a straight-forward question of identity: "Who am I?"
  52. 52. • Too much "ego identity," where a person is so involved in a particular role in a particular society that there is no room left for tolerance. This maladaptive tendency is called fanaticism. • The lack of identity is referred as repudiation, they repudiate their need for an identity. Some adolescents allow themselves to "fuse" with especial kind of group that is particularly eager to provide the details of their identity. • If one successfully negotiate this stage, he will have the virtue of fidelity. Fidelity means loyalty, the ability to live by societies standards despite their imperfections and and inconsistencies ,a person has found a place in that community, a place that will allow him to contribute.
  53. 53. • Most orthodontic treatment is carried out during the adolescent years, and behavioral management of adolescents can be extremely challenging. Since parental authority is being rejected, 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.
  54. 54. Approval of the peer group is extremely important. At one time, there was a certain stigma attached to being the only one in the group so unfortunate as to have to wear braces. Now, orthodontic treatment has become so common that there may be a loss of status attached to being one of the few in the group who is not receiving treatment, so that treatment may even be requested in order to remain "one in the crowd." In this stage, abstract concepts can be grasped readily, but appeals to do something because of its impact on personal health are not likely to be heeded. The typical adolescent feels that health problems are concerns of somebody else, and this attitude covers everything from accidental death in reckless driving to development of decalcified areas on carelessly brushed teeth during orthodontic treatment.
  55. 55. • Stage of young adulthood(18 to about 30yr) • The task is to achieve intimacy, as opposed to remaining in isolation. • Intimacy is the ability to be close to others, as a lover, a friend, and as a participant in society .A person has clear sense of who he is , he no longer need to fear of "losing" himself, as many adolescents do. • The maladaptive form called as promiscuity, referring particularly to the tendency to become intimate too freely, too easily, and without any depth.
  56. 56. • 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. • If one successfully negotiate this stage, he will carry with him the virtue called love. Love, means being able to put aside differences and antagonisms through "mutuality of devotion." It includes not only the love we find in a good marriage, but the love between friends and the love of one's neighbor, coworker etc.
  57. 57. • 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.
  58. 58. • The factors that affect the development of an intimate relationship include all aspects of each person—appearance, personality, emotional qualities, intellect, and others. A significant change in any of these may be perceived by either partner as altering the relationship. Because or these potential problems, the potential psychological impact of orthodontic treatment must be fully explained to and explored with the young adult patient before beginning therapy
  59. 59. 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. • More obvious, of course, is the malignant tendency of rejectivity. Too little generativity and too much stagnation and you are no longer participating in or contributing to society.
  60. 60. 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. • Ego 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.
  61. 61. • The maladaptive tendency is called presumption. This is what happens when a person "presumes" ego integrity without actually facing the difficulties of old age. • The malignant tendency is called disdain, which means a contempt of life. • Someone who approaches death without fear has the strength, Erikson calls wisdom. He calls it a gift to children, because "healthy children will not fear life if their elders have integrity enough not to fear death."
  62. 62. Cognitive Theory-Jean Piaget (1952) • Jean Piaget began his career as a mycologist. But his interest in science soon overtook his interest in snails and clams. As he delved deeper into the thoughtprocesses , he became interested in the nature of thought itself, especially in the development of thinking. He called it genetic epistemology, meaning the study of the development of knowledge.
  63. 63. • Process of cognitive development: Piaget believed that every individual is born with the capacity to adjust and adapt to both physical and sociocultaral environment in which he or she live in. He described two processes used by the individual in its attempt to adapt: assimilation and accomodation. • Assimilation is the process of incorporation of events within environment into mental categories called cognitive structures or schemas • Accomodation is the process of changing cognitive structures to better represent the environment. Both processes are used simultaneously and alternately throughout life. • As schemes become increasingly more complex (i.e., responsible for more complex behaviors) they are termed structures. As one's structures become more complex, they are organized in a hierarchical manner (i.e., from general to specific).
  64. 64. • Assimilation and accommodation work like a pendulum, swings at advancing our understanding of the world and our competency in it. They both are directed to attain a balance between the structure of the mind and the environment, and that ideal state is called as equilibrium. • As Piaget continued his investigation of children, he noted that there were periods where assimilation dominated, periods where accommodation dominated, and periods of relative equilibrium, and that these periods were similar among all the children he looked at in their nature and their timing. And so he developed the idea of stages of cognitive development.
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  67. 67. The sensorimotor stage ( from birth to two years) • As the name implies, the infant uses senses and motor abilities to understand the world, beginning with reflexes and ending with complex combinations of sensorimotor skills. • Between one and four months, the child works on primary circular reactions -- just an action of his own which serves as a stimulus to which it responds with the same action, and around and around. • Between four and 12 months, the infant turns to secondary circular reactions, which involve an act that extends out to the environment: She may squeeze a rubber duckie. It goes quack. That is great, so do it again, and again. She is learning procedures that make interesting things last.
  68. 68. • Between 12 months and 24 months, the child works on tertiary circular reactions. They consist of the same making interesting things last cycle, except with constant variation. I hit the drum with the stick -- rat-tat-tat-tat. I hit the block with the stick -thump-thump .I hit daddy with the stick -- ouchouch. This kind of active experimentation is best seen during feeding time, when discovering new and interesting ways of throwing spoon, dish, and food. • Around one and a half, the child is clearly developing mental representation, that is, the ability to hold an image in their mind for a period beyond the immediate experience. They can use mental combinations to solve simple problems, such as putting down a toy in order to open a door.
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  71. 71. Preoperational stage (two to about seven years). • The child is quite egocentric during this stage, that is, he sees things pretty much from own point of view. • Piaget did a study to investigate this phenomenon called the mountains study. He would put children in front of a simple plaster mountain range and seat himself to the side, then ask them to pick from four pictures the view that he, Piaget, would see. Younger children would pick the picture of the view they themselves saw; older kids picked correctly.
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  74. 74. • The most famous example of the preoperational child's centrism is what Piaget refers to as their inability to conserve liquid volume. If we give a three year old some chocolate milk in a tall skinny glass, and we give ourself a whole lot more in a short fat glass, she will tend to focus on only one of the dimensions of the glass. Since the milk in the tall skinny glass goes up much higher, she is likely to assume that there is more milk in that one than in the short fat glass, even though there is far more in the latter. It is the development of the child's ability to decenter which marks him as having moved to the next stage.
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  76. 76. Mom, cut it into a lots of slices ,I am really hungry
  77. 77. • At this stage, capabilities for logical reasoning are limited, and the child's thought processes are dominated by the immediate sensory impressions. So the dental staff should use immediate sensations rather than abstract reasoning in discussing concepts like prevention of dental problems with a child at this stage. Excellent oral hygiene is very important when an orthodontic appliance is present. A preoperational child will have trouble understanding a chain of reasoning like the following: "Brushing and flossing remove food particles, which in turn prevents bacteria from forming acids, which cause tooth decay."
  78. 78. • He is much more likely to understand: "Brushing makes your teeth feel clean and smooth” and, "Toothpaste makes your mouth taste good” because these statements rely on things the child can taste or feel immediately. Another characteristic of thought process in this stage is Animism-investing inanimate objects with life. For example while talking to a 4-year-old about how desirable it would be to stop thumb sucking .The orthodontist might have only little problem in getting the child to accept the idea that "Mr. Thumb" was the problem and that the dentist and the child should form a partnership to control Mr. Thumb who wishes to get into the child's mouth. Animism, in other words, can be applied even to parts of the child's own body, which seem to take on a life of their own in this view.
  79. 79. • On the other hand, it would not be useful to point out to the child how proud his father would be if he stopped sucking his thumb, since the child would think his father's attitude was the same as the child's (egocentrism). Since the child's view of time is centered around the present, and he or she is dominated by how things look, feel, taste, and sound now, there is no point in talking to the 4-year-old about how much better his teeth will look in the future if he stops sucking his thumb. Telling him that the teeth will feel better now or talking about how bad his thumb tastes, however, may make an impact, since he can relate to that.
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  82. 82. • • • • Concrete operations stage ( 7 to11 yrs). The word operations refers to logical principles we use when solving problems. In this stage, the child not only uses symbols representationally, but can manipulate those symbols logically. But, at this point, they still perform these operations within the context of concrete situations. The stage begins with progressive decentering. By six or seven, most children develop the ability to conserve number, length, and liquid volume. Conservation refers to the idea that a quantity remains the same despite changes in appearance. And he will know that you have to look at more than just the height of the milk in the glass: If we pour the milk from the short, fat glass into the tall, skinny glass, he will tell us that there is the same amount of milk as before, despite the dramatic increase in milk-level!
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  84. 84.     If we take a ball of clay and roll it into a long thin rod, or even split it into ten little pieces, the child knows that there is still the same amount of clay. And he will know that, if we rolled it all back into a single ball, it would look quite the same as it did -- a feature known as reversibility. • By nine or ten, the last of the conservation tests is masteredconservation of area. • In addition, a child learns classification and seriation during this stage. Now the child begins to get the idea that one set can include another. • Seriation is putting things in order. The younger child may start putting things in order by, say size, but will quickly lose track. Now the child has no problem with such a task. Since arithmetic is essentially nothing more than classification and seriation, the child is now ready for some formal education!
  85. 85. • By this stage, the ability to see another point of view develops, while animism declines .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. Instructions must be illustrated with concrete objects "Now wear your retainer every night and keep it clean," is too abstract. More concrete direction would be: "This is your retainer. Put it in your mouth like this, and take it out like that. Put it in every evening after dinner before you go to bed, and take out before breakfast every morning. Brush it like this with old toothbrush to keep it clean”.
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  87. 87. Formal operations stage . (12 yrs to adult) Around 12 yrs of age, child enter the formal operations stage. Here he become increasingly competent at adult-style thinking. This involves using logical operations, and using them in the abstract, rather than the concrete. We call this as hypothetical thinking. Child is capable of understanding concepts like health ,disease ,preventive treatment etc. At this child should be treated like an adult.
  88. 88.  A new expression of egocentrism develops , they presume that they and others are thinking about the same thing. Because young adolescents are experiencing tremendous biologic changes in growth and sexual development, they are preoccupied with these events. When an adolescent considers what others are thinking about, he assumes that others are thinking about the same thing he is thinking about, namely himself. Adolescents assume that others are as concerned with their bodies, actions, and feelings as they themselves are. They feel as though they are constantly "on stage," being observed and criticized by those around them. This phenomenon has been       
  89. 89. • The imaginary audience is a powerful influence on young adolescents, making them quite self conscious and particularly susceptible to peer influence. They are very worried about what peers will think about their appearance and actions, not realizing that others are too busy with themselves to be paying attention to much other than themselves.
  90. 90. • The reaction of the imaginary audience to braces on the teeth, is an important consideration to a teenage patient. As orthodontic treatment has become more common ,adolescents have less concern about being singled out because they have braces on their teeth, but they are very susceptible to suggestions from their peers about how the braces should look. This has led to pleas for tooth-colored plastic or ceramic brackets to make them less visible. • Brightly colored ligatures and elastics have also become popular among adolescent ,they feel that everybody is wearing them so they should also be ‘ in the crowd’. • The notion that "others really care about my appearance and feelings as much as I do" leads adolescents to think they are quite unique, special individuals. Because of this thought process a second phenomenon emerges which is called as” personal fable”. • This concept holds that “because I am unique, I am not subject to the consequences others will experience."
  91. 91. Both the imaginary audience and the personal fable are likely to have significant influence on orthodontic treatment. The imaginary audience, depending on what the adolescent believes, may influence him to accept or reject treatment, and to wear or not to wear appliances. The personal fable may make a patient ignore threats to health, such as decalcification of teeth from poor oral hygiene during orthodontic therapy. The thought is "Others may have to worry about that, but I don't."
  92. 92. • The challenge for the orthodontist is not to try to impose change on reality as perceived by adolescents, but rather to help them to see more clearly the actual reality that surrounds them. • A teenage patient may protest to his orthodontist that he does not want to wear a particular appliance because others will think it makes him "look goofy." In this situation, telling the patient that he should not be concerned because many of his peers also are wearing this appliance does little to encourage him to wear it.
  93. 93. • A more useful approach is that do not deny the point of view of the patient , agree with him that he may be right in what others will think, but ask him to give it a try for a specified time. If his peers do respond as the teenager predicts, then a different, but less desirable treatment technique can be discussed. This test of the teenager's perceived reality usually demonstrates that the audience does not respond negatively to the appliance or that the patient can successfully cope with the peer response.
  94. 94. • Criticisms of Psychodynamic Approaches • Freud’s theories overemphasized the unconscious mind, aggression, and childhood experiences. • Many of the concepts proposed by psychodynamic theorists are difficult to measure and quantify. • Strengths of Psychodynamic Approaches • While most psychodynamic theories did not rely on experimental research, the methods and theories of psychodynamic thinking contributed to experimental psychology. • Many of the theories of personality developed by psychodynamic thinkers are still influential today, including Erikson’s theory of psychosocial stages and Freud’s psychosexual stage theory.
  95. 95. Social Learning Theory-Albert Bandura (1963) • Albert Bandura was born December 4, 1925, in the small town of Mundare in northern Alberta, Canada. • He received his bachelors degree in Psychology from the University of British Columbia in 1949. He went on to the University of Iowa, where he received his Ph.D. in 1952. • It was there that he came under the influence of the behaviorist tradition and learning theory.
  96. 96. Theory • He suggested that environment causes behavior, but behavior causes environment also. He called this concept as reciprocal determinism. The world and a persons behavior cause each other. • Development of personality takes place as an interaction among three things: the environment, behavior, and the persons psychological processes. These psychological processes consist of our ability to entertain images in our minds, and language.
  97. 97.      According to Bandura the steps involved in the modeling are: • 1. Attention. If we are going to learn anything, we have to be pay attention. Likewise, anything that puts a damper on our attention is going to decrease learning, including observational learning. • Main thing that influence attention involves characteristics of the model. If the model is colorful and dramatic, we pay more attention. If the model is attractive, or prestigious, or appears to be particularly competent, we will pay more attention. And if the model seems more like our self, we will pay more attention.
  98. 98. 2. Retention. Second, we must be able to retain what we have paid attention to. This is where imagination and language come in. We store what we have seen the model doing in the form of mental images or verbal descriptions. When so stored, we can later bring up the image or description, so that we can reproduce it with our own behavior. 3. Reproduction. we have to translate the images or descriptions into actual behavior. So we have to have the ability to reproduce the behavior in the first place.
  99. 99. 4. Motivation. And yet, with all this, we are still not going to do anything unless we are not motivated to imitate, i.e. until we have some reason for doing it. Bandura mentioned following motives: a. past reinforcement. b. promised reinforcements - incentives. • Of course, the negative motivations are there as well, giving us reasons not to imitate someone: a. past punishment. b. promised punishment (threats).
  100. 100. • Children are capable of performing almost any behavior that they observe closely and that is not too complex for them to perform at their level of physical development. • Most of the behavior which he acquires may not be expressed immediately or ever. • Whether a child will actually perform an acquired behavior depends on several factors. Important among these are: A) Role model. If the model is liked or respected, the child is more likely to imitate him or her. For this reason, a parent or older sibling is often the object of imitation by the child. For children in the elementary and junior high school age group, individuals slightly older, are important role models. For adolescents, the peer group ,is the major source of role models.
  101. 101. B) Possible outcome :If the outcome is good and pleasing such as reward ,than chances of repeating the behavior is more than if it is bad. • Observational learning can be an important tool in management of dental treatment. If a young child observes an older sibling undergoing dental treatment without complaint or uncooperative behavior, he or she is likely to imitate this behavior. If the older sibling is observed being rewarded, the younger child will also expect a reward for behaving well
  102. 102. . • Research has demonstrated that one of the best predictors of how anxious a child will be during dental treatment is how anxious the mother is. A mother who is calm and relaxed about the prospect of dental treatment teaches the child by observation that this is the appropriate approach of being treated, whereas an anxious and alarmed mother tends to elicit the same set of responses in her child.
  103. 103. • Observational learning can be used to advantage in the design of treatment areas. At one time, it was routine for dentists to provide small private cubicles in which all patients, children and adults, were treated. The modern trend, particularly in treatment of children and adolescent, is to carry out dental treatment in open areas with several treatment stations. • Sitting in one dental chair watching the dentist working with someone else in an adjacent chair can provide a great deal of observational learning about what the experience will be like.
  104. 104. • Direct communication among patients, answering questions about exactly what happened, can add even further learning. Both children and adolescents do better,if they are treated in open clinics rather than in private cubicles, and observational learning plays an important part in this. The dentist hopes, of course, that the patient waiting for treatment observes appropriate behavior on the part of the patient who is being treated.
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  106. 106. Classical Conditioning Theory-Ivan Pavlov (1927) Classical Conditioning. • Described by the Russian physiologist Ivan Pavlov, who discovered during his studies of reflexes that apparently unassociated stimuli could produce reflexive behavior. • Pavlov's classic experiments involved the presentation of food to a hungry animal, along with ringing of a bell. The sight and sound of food normally elicit salivation by a reflex mechanism. If a bell is rung each time food is presented, the auditory stimulus of the ringing bell will become associated with the food presentation stimulus, and in a relatively short time, the ringing of a bell by itself will elicit salivation. Classical conditioning, operates by the simple process of association of one stimulus with another, and some times also referred as learning by association.
  107. 107. • Classical conditioning can have a considerable impact on a young child's behavior on the first visit to a dental office. By the time a child is brought for the first visit to a dentist, it is highly likely that he or she will have had many experiences with pediatricians and medical personnel. When a child experiences pain, the reflex reaction is crying and withdrawal. In Pavlovian terms, the infliction of pain is an unconditioned stimulus, but a number of aspects of the setting in which the pain occurs can come to be associated with this unconditioned stimulus.
  108. 108. • If the unconditioned stimulus of painful treatment comes to be associated with the conditioned stimulus of white coats, a child may cry and withdraw immediately at the first sight of a white coated dentist or dental assistant. In this case, the child has learned to associate the unconditioned stimulus of pain and the conditioned stimulus of a white coated adult, and the mere sight of the white coat is enough to produce the reflex behavior initially associated with pain.
  109. 109.
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  111. 111.
  112. 112.     Associations of this type tends to become: A) Generalized: Painful and unpleasant experiences associated with medical treatment can become generalized to the atmosphere of a physician's office, so that the whole atmosphere of a waiting room, receptionist, and other waiting children may produce crying and withdrawal after several experiences in the physician's office, even if there is no sign of a white coat. • Because of this association, behavior management in the dentist's office is easier if the dental office looks different from the typical pediatrician's office or hospital clinic.
  113. 113. B) Discrimination: If a child is taken into other office settings which are somewhat different from the one where painful things happen, a dental office, for instance, where painful injections are not necessary, a discrimination between the two types of offices soon will develop and the generalized response to any office as a place where painful things occur will be extinguished.
  114. 114.    In practices where the dentist and auxilaries work with young children, they have found that it is helpful in reducing children's anxiety if their appearance is different from that associated with the physician. It also helps if they can make the child's first visit as different as possible from the previous visits to the physician. Treatment that might produce pain should be avoided if at all possible on the first visit to the dental office. C) Strengthened or reinforced: Every time a child is taken to a hospital clinic where something painful is done, the association between pain and the general atmosphere of that clinic becomes stronger, as the child becomes more sure of his conclusion that bad things happen in such a place.
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  116. 116. D) Extinction: If the association between a conditioned and an unconditioned stimulus is not reinforced, the association between them will become less strong, and eventually the conditioned response will no longer occur. This phenomenon is referred to as extinction of the conditioned behavior. If the conditioned association of pain with the doctor's office is strong, it can take many visits without unpleasant experiences and pain to extinguish the associated crying and avoidance.
  117. 117. Operant Conditioning Theory-Skinner (1938) • Burrhus Frederic Skinner was born March 20, 1904, in Pennsylvania • He got his masters in psychology in 1930 and his doctorate in 1931 from Harvard, and stayed there to do research until 1936.
  118. 118. • The basic principle of operant conditioning is that the consequence of a behavior is in itself a stimulus that can affect future behavior. • In classical conditioning, a stimulus leads to a response; in operant conditioning, a response becomes a further stimuli. • The general rule is that if the consequence of a certain response is pleasant, that response is more like to be used again in the future; but if a particular respond produces an unpleasant consequence, the probability that response being used in the future is diminished.
  119. 119. Stimulus Response Consequence
  120. 120. • Skinner described four basic types of operant conditioning distinguished by the nature of the consequence . • A) Positive reinforcement. If pleasant consequence follows a response, the response has been positively reinforced, and the behavior that led to the pleasant consequence becomes more likely in the future .
  121. 121.
  122. 122.
  123. 123. B) Negative reinforcement: involves the withdrawal of an unpleasant stimulus after a response. Like positive reinforcement, negative reinforcement also increases the likelihood of a response in the future. The word negative merely refers to the fact that the response that is reinforced is a response that leads to the removal of an undesirable stimulus. If behavior of the child which is considered unacceptable by the dentist and his staff ,helps the child to escape from dental treatment, then the behavior is negatively reinforced and is more likely to occur the next time the child is in the dental office. So it is important to reinforce only desired behavior, and it is equally important to avoid reinforcing not desired . behavior that is
  124. 124.
  125. 125. C) Omission : Involves removal of a pleasant stimulus after a particular response. For example, if a child who throws a temper tantrum, has his favorite toy taken away for a short time as a consequence of this behavior, the probability of similar misbehavior is decreased.
  126. 126. D) Punishment: Occurs when an unpleasant stimulus is presented after a response. This also decreases the probability of similar kind of behavior that prompted punishment in the future. Punishment is effective at all ages, not just with children. • In general, positive and negative reinforcement are the most suitable types of operant conditioning for use in the dental office, particularly for motivating orthodontic patients. Both types of reinforcement increase the likelihood of a particular behavior recurring, rather than attempting to suppress a behavior as punishment and omission do. Simply praising a child for desirable behavior produces positive reinforcement, and additional positive reinforcement can be achieved by presenting some tangible reward.
  127. 127. • Adolescents in the orthodontic treatment, for instance, can obtain reinforcement from a simple pin saying, ' Worlds greatest Orthodontic Patient" or something similar. A reward such as T-shirt with some slogan as a prize for three consecutive appointments with good behavior is another simple example of positive reinforcement .
  128. 128. • Negative reinforcement, which also accentuates the probability of any given behavior, is more difficult to utilize as a behavioral management tool in the dental office, but it can be used effectively if the circumstances permit. If a child is concerned about a treatment procedure but behaves well and understands that the procedure has been shortened because of his good behavior, the desired behavior has been negatively reinforced. • In orthodontic treatment, long bonding and banding appointments may go more efficiently and smoothly if the child understands that his helpful behavior has shortened the procedure and reduced the possibility that the procedure will need to be redone.
  129. 129. • Concepts of reinforcement as opposed to extinction, and generalization as opposed to discrimination, apply to operant conditioning as well as to classical conditioning. • In operant conditioning, the concepts apply to the situation in which a response leads to a particular consequence, not to the conditioned stimulus that directly controls the conditioned response. • Positive or negative reinforcement becomes even more effective if repeated, although it is not necessary to provide a reward at even visit to the dental office to obtain positive reinforcement. Similarly, conditioning obtained through positive reinforcement can be extinguished if the desired behavior is now followed by omission, punishment, or simply a lack of further positive reinforcement.
  130. 130. • Operant conditioning that occurs in one situation can also be generalized to similar situations. For example, a child who has been positively reinforced for good behavior in the pediatrician's office is likely to behave well on the first visit to a similarly equipped dentist's office because he or she will anticipate a reward at the dentist's also, based on an assessment of the similarity of the situation. A child who continues to be rewarded for good behavior in the pediatrician's office but does not receive similar rewards in the dentist's office, however, will learn to discriminate between the two situations and may eventually behave better for the pediatrician than for the dentist.
  132. 132. Psychological Management of Orthodontic Patient : Louis Norton- AO July 1971 • • • • Young child (6 to 9 yrs) 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 your treatment. • Careful explain about what you intend to do and a brief why, using language that the child can understand. • This may be supplemented with charts, simple stories which the child can read himself or short single concept films.
  133. 133. • 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. This is why most children of this age respond well to tooth brushing charts and tables which allow them to see how well they are progressing. This, in effect, is a simplified teaching machine. • Praise should be given freely as a means of reenforcement. The bribe of a toy for good behavior from the dentist decreases their desire to know what is happening to them. Bribery should therefore not be used.
  134. 134. • It is difficult to use removable appliances in children from six to nine. - 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.
  135. 135. : • Early Adolescent (ten to thirteen yrs) : Boys: • Retains his curiosity about the "why" of treatment during this period, but the "how" begins to capture his imagination. • He is fascinated by scientific instruments and mechanical gadgets. • He is also looking for a hero, to emulate. It is not unusual for a personable dentist to fill this hero's role for the child.
  136. 136. • To gain cooperation from a boy of this age group, one must show interest in his interests. One must again be careful to explain each procedure to the child and why. "Show and tell" explanations will lead him to ask "how do you do that, or how does this machine work?". Let him observe operative procedures through a hand mirror. Allow him to hold some materials such as periphery wax, alginate or blunt hand instruments. If he seemed quite excited by this, the reward of a trip to the laboratory will turn the young patient into a fast friend.
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  138. 138. Female : • Quite different from the boy but an equal challenge. • She is passionately interested in her developing body. Any dental procedure that might affect her looks is either accepted with exuberance or dread. • She is very susceptible to flattery which can lead to the ''crush syndrome" which can be a management problem. • She is very gossipy . Efforts to establish rapport through conversation can end up as a talked away appointment.
  139. 139. • Friendliness may be demonstrated by a smile and a compliment on behavior or an achievement. • References to her body, may invite problems. For example if you say she has got-ten quite tall. • The conversation should be brief, pleasant, impersonal and thoughtful.
  140. 140. • • • • The Teenage (fourteen to eighteen yrs) :Male: Express the adult image which is usually overtly uncomfortable for him. He wishes to be treated as an adult but often express himself as an irrational child . His interests have now narrowed to normal development of his body, acceptance by his peers. He spends hours primping himself in the mirror. He is desperately fighting anything that makes him look different from the group with whom he identifies. Management of the teenage male is a matter of sympathy and understanding.
  141. 141. • One must be direct and forthright. Being devious or overly complex will lead to suspicion. • Trust is the most valuable asset to be sought from this age group. • It is important that treatment plans be discussed with the same logic, responsibility and firmness, as with an adult patient. This allows the boy to assume the adult role which will soon be reality. • If discipline becomes a problem the dentist has an advantage. He is an authority figure outside the family. The chances are good that a boy will readily discuss why he is not following your instructions.
  142. 142. 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 immediate body image or, if she has an unaesthetic malocclusion, they offer a promise. • The thrust in management must be toward the cosmetic and status value.
  143. 143. • Once trust is established, she will usually be cooperative , probably due to her earlier maturity. Discipline should again be handled by discussing the root of the problem and its various solutions rather than making “parent like” demands for cooperation. • Latent crush syndromes can occur in this age group, particularly in girl with the unaesthetic malocclusion. The orthodontist is freeing her of her problem. He takes on the proportions of a hero.
  144. 144. • They are trying to assume the role of an adult and they do not believe their parents have an understanding of any of their problems. Therefore detailed consultations and progress reports should be given to the parent and child, but separately. • The patient will take comfort in knowing that his parents are concerned about his treatment, but the patient will take offense if she feels they are directing it. The primary relationship is with the child and not with the parents.
  145. 145. Conclusion The dentist's message must be presented in terms that correspond to the stage of cognitive and psychosocial development that a particular child has reached. It is the job of the dentist to carefully evaluate the development of the child, and adapt his or her language so that concepts are represented in a way that the patient can understand them.
  146. 146. The adage "different strokes for different folks" applies strongly to children, whose variations in intellectual and psychosocial development affect the way they receive orthodontic treatment, just as their differing stages of physical development do.
  147. 147. REFERENCES 1. Moyers Robert E.: Hand book of Orthodontics. Year book Medical publishers, Inc, 198; 4th Edition. 2. Bishara Samir E.: Text book of Orthodontics. Saunders 2003.456-462. 3. Proffit W R: Contemporary Orthodontics. Mosby 2000.3rd Edition.48-61.
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  152. 152. Thank you For more details please visit