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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

  1. 1. Definition • Psychology is the science dealing with human nature, function and phenomenon of his soul in the main. • Child psychology is the science that deals with the mental power (or) an interaction between the conscious and subconscious element in a child INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Importance of child psychology • To understand the child better • To know the problem of psychological origin • To deliver dental services in a meaningful and effective manner • To establish effective communication with child and the parent. • To gain confidence of the child and of the parent • To teach the child and the parent. • To have better treatment planning & interaction with other discipline. • To produce comfortable environment for the dental team to work on the patient.
  3. 3. DEVELOPMENTAL TASKS • BIOLOGICAL: • COGNITIVE: • EMOTIONAL: • SOCIAL: • Motor function and adaptation of skills • Awareness and intellectual development • Personality development of the child. • Social experience , morals of society
  4. 4. Theories of child psychology • Child psychology theories can be broadly classified into two groups. (1)Psychodynamic theories • Psycho sexual theory - Freud(1905) • Psycho social theory - Eric Erickson(1963) • Cognitive theory - Piaget(1952)
  5. 5. (2) Behavioral theories • Hierarchy of needs - Maslow(1954) • Social Learning Theory - Bandura(1963) • Classical conditioning - Pavlov(1927) • Operant conditioning - Skinner(1938) • Mahler’s theory(1933)
  7. 7. HOWARD GARDNER COGNITIVE STRUCTURAL THEORIES Jean piaget, Laurance Kohlberg,Deanna Kuhn PERSONALITY OR DYNAMIC PSYCHOLOGY Sigmond Freud, Eric Erickson, Bruno Bettelheim BEHAVIOURIST MODELLING THEORIES B.F.Skinner, Albert Bandura
  8. 8. • ENVIRONMENTAL LEARNING THEORIES Tracy Kendler, Alexander Luria. • ORGANISMIC DEVELOPMENTAL THEORIES Heinz Wernier, Douglass Carmichael. • ANTHROPOLOGICAL THEORIES Michel Lole, Margret Mead, John Whiting.
  9. 9. PETER HOARE • STAGE THEORIES Piaget Sigmond Freud • NON STAGE THEORIES Learning Theories
  10. 10. Psychosexual theory • Sigmond Freud (1905)- originator of psychoanalytical approach. • personality to originate from biological and maturational components with an invariant sequence of development to everyone • categorized into 5 psychosexual stages • At each stage sexual energy is integrated in a particular part called erogenous zone. • Two categories in concept of Freudian theory - level of consciousness (or) awareness - functional component is personality
  11. 11. There are three levels of consciousness • Conscious – a part of personality which is aware of thoughts and feelings for basic activities • Preconscious – a part of personality of which the individual is not aware of at the moment however able to recollect into awareness without great difficulty. • Unconscious -part of personality of which individual is unaware, which generally cannot able to bring into awareness without help of assistant
  12. 12. ID • Basic structure of personality which serves as the reservoir of instincts FEATURES OF ID Present at birth Impulse ridden (instinctual) Strive for immediate pleasure and gratification Selfish and Cannot with stand pain Retention Aggressive Personality
  13. 13. SUPER EGO • Acts as a censor for acceptability of thoughts, feelings and behaviour . • In short, it is the conscious that instructs us on what to do and not to. • It is determined by the restrictions imposed by the parents, society and culture ,i.e. morals and ethics • It is developed by initial reward and punishment. • Over punishment leads to decrease in libido and instinctual development. • Proper parenting is important.
  14. 14. WEAK SUPER EGO • Only the Id factor plays, due to no moral teaching. This kind of personality can make the child a criminal at later ages.
  15. 15. EGO • Mediator between ID and Super ego. • Develops out of ID in the 2nd to 6th month of life • It modifies the ID and form the executive part of the personality • Concerned with memory and judgment (REALITY PRINCIPLE) • Seat of consciousness. • It is the actual reality we experience
  16. 16. Functions of ego • Defense mechanism – prevents the instinctual impulses from the ID and reduces the level of anxiety. • As a positive function in that the individual is able to avoid crisis. • As a negative function in that they cause self deception and prevent the individuals from accepting the realities of life. • Composed of escape and compromise techniques
  17. 17. TYPES OF DEFENCE MECHANISM • PROJECTION: Individual projects ,personal feelings of inadequacy onto someone in order to feel more comfortable. • DENIAL: Inability to accept the psychological impact of a potentially stressful event . • UNDOING:In an attempt to undo the harm, an individual imagines what his ID produces. • IDENTIFICATION: assumption of qualities of some one else to vent frustration or create fantasy (imitation)
  18. 18. REGRESSION:When an anxiety producing situation comes the child shows an age in an appropriate response, i.e. behavioural relapse to a more infantile manner. REACTION FORMATION:Transfer of hostile or more aggressive impulses into their opposite or more socially desirable form. REPRESSION: The process of unconscious forgetting which allows the suppression, painful experiences into subconscious mind.
  19. 19. • RATIONALISATION: A strategy developed to excuse or minimize the psychological consequences of an event. • SUBLIMATION: Redirection of socially unacceptable drives into socially approved channels to allow the discharge of instinctive impulses in an acceptable form. • DISPLACEMENT: The transfer of hostile and aggressive feelings from a original source to another, usually a less important one.
  20. 20. STAGES OF DEVELOPMENT • ORAL STAGE (0 to 1) • Peri oral region is the area of pleasure and gratification • Adequate and regular feeding is very important. • A proper balance between too much and too little or that particular trait will become fixated at that stage. • passiveness and dependence. • Additive behaviour like overeating, excessive optimism, envy, jealousy pessimism, demandingness etc • Satisfaction of this stage helps in the development of trust and in later years it result in successful achievements of needs.
  21. 21. • ANAL STAGE (2-3) • Anal region- the zone of pleasure. • Ego centric or self centered behaviour • Maturation of his neuromuscular control. • Child become more independent and develops personal autonomy. • Over emphasis of toilet training causes compulsive ,obstinate ,and perfectionist behaviour in later life. • ANAL PERSONALITY: Characterized by disorderliness abstinence, stubbornness, willfulness, frugality. • Less controlled management of toilet training causes an impulsive personality
  22. 22. PHALLIC STAGE (3-5yrs) Child becomes increasingly aware of his or her genitals, he can differentiate the sexes. CHARECTERISTICS Oedipus complex: boys become attached to his mother. Castration anxiety Resolution of this crisis for boys is to identify with his father and use him as a role model.
  23. 23. Electra complex :opposite of Oedipus complex. Girls get attached to father Penis envy: seen in females with lasting Electra complex Emergence of super ego or conscience Sense of shame and guilt Emergence of jealous and competitive feelings towards peers and siblings Unsatisfactory resolution leads to sexual conflicts and inability to perform sexual relationship, male and female homosexuality etc
  24. 24. • LATENCY STAGE (5-12yrs) • Period of consolidation • More importance is on peer development and character formation • Greater degree of control over instinctual impulses • Lack of resolution of this stage can lead to immature behaviour and decreased development of skills • Males tend to act as females and females tends to act as males (TOM BOY)
  25. 25. • GENITAL STAGE (12-18yrs) • Spurt in sexual activity • Hormonal and physiological changes increase the interest in sexual matters • Most important stage that shapes the future of a child are oral and phallic stages.A successful resolution of oral stages give the foundation of close trusting relationship while unresolved phallic stage leads to confusion over sexual role and behaviour.
  26. 26. COGNITIVE DEVELOPMENT Jean Piaget 1952 • Survival of the fittest and the most adaptable is the driving force for development. • Cognitive development is the interaction between the individual and the environment
  27. 27. FOUR MAJOR ASPECTS OF COGNITIVE DEVELOPMENT  Progressive neurological development  Child has the opportunity to practice newly acquired skills.  The opportunity for social interaction  Internal psychological mechanism or structures emerge that allows the child to construct successively more complex cognitive models based on maturation and experience.
  28. 28. PIAGETS MAJOR CONCEPTS • Two types of cognitive structure Schemas and operations SCHEMAS Simple mental structure present at birth Internal representation of some specific action or behaviour.
  29. 29. OPERATIONSOPERATIONS Develop later in cognitive development More complex Represent internal structures of a high order that have the distinctive features of being reversible
  30. 30. Adaptation of cognitive structure By two process Assimilation: Refers to incorporation of new objects ,thoughts,and behaviour into existing structures. Accommodation: Is the change of existing structures in response to novel experiences Equilibration : Is the means by which the individual balances the competing forces of assimilation and accommodation.
  31. 31. PIAGETS STAGES OF COGNITIVE DEVELOPMENT • Sensorimotor period (birth to 2yrs) • Preoperational period (2-7yrs) • Concrete operational (7-12 yrs) • Formal operational period (>12yrs)
  32. 32. Sensorimotor (0 to 2 years) • Child born with certain basic characters for interacting with the environment. • This primitive strategies mark the beginning of the thinking process. • Child does not yet have the capacity to represent object (or) people to himself mentally. • As maturation progresses the simple reflexes begin to be coordinated. • E.g. arm is moved, eyes keep on watching it • By l0th month, variety of elementary schemes develop. • Permanent relating of object develops in course of coordinating actions with repeated contacts with environment
  33. 33. Pre-operational stage (2–6 yrs) • Primitive strategies change in the child. Assimilates new experiences and accommodates original strategies. • The child uses symbols in language with play. • Learns to classify things. • solves problems as a result of intuitive thinking but cannot explain why
  34. 34. Concrete operation stage (6-12 years) • The thinking process becomes logical • Ability to use complex mental operations such as addition and subtraction. • Child is able to understand others point of view. • Development based on the level of understanding achieved so far
  35. 35. Formal operational stage (11-15 yrs) • Child able to think more abstractly. • Uses inductive (or) deductive logic to make decisions to solve problems. • Thinks of ideas and has developed a vast imagination.
  36. 36. MERITS AND DEMERITS Research works have failed to demonstrate the existence of cognitive structures. Children are consistently inconsistent in their approach to problem solving despite using the same cognitive structures. Lately it has been suggested that this inadequacy in problem solving are related to memory power of the child rather than cognitive ability.
  37. 37. PSYCHOSOCIAL THEORY ERIC ERICKSON • Social and cultural dimension to developmental theory • Elaborated phase or stage theory covering the whole life span from birth to death. • Emphasized the conscious self as much as unconscious instincts
  38. 38. • In Erickson’s view “Psychosocial development proceeds by critical steps – ‘critical’ being characteristics of turning points, moments of decision between progression, integration and retardation. Each stage represents a “psychosocial crisis” influenced by social environment. • Chronological ages are associated with Erickson’s developmental stages as in physical development, the chronological age varies among individuals but developmental stage remains constant. • Erickson emphasizes on the conscious self as much as unconscious instincts. • Development depends upon child’s instincts and responses of those around him. • Unresolved issues from early stages of life affect persons ability to deal with subsequent stages.
  40. 40. Erickson’s stages of emotional development Development of Basic trust (Birth to 18 months) • Initial stage of emotional development a basic trust (or) lack of trust in the environment is developed. • Successful development of trust depends on a caring and consistent mother (or) mother-substitute who meets both the physiologic and emotional needs of the infant. • Bond between child and mother should be maintained to develop basic trust. If it fails leads to maternal deprivation.
  41. 41. TASK Establishment of social relationships • Good outcome –secure stable relationship • Bad outcome –insecure ,unsatisfactory relationships
  42. 42. Development of Autonomy (18 months-3 years) • Around the age of 2 yrs children called terrible two’s because of their un co-operative and obnoxious behaviour. • Emotional development moving away from mother by developing a sense of individual identity (or) autonomy. • At this stage, wetting one’s pants produces a feeling of shame. • Allowing the parent to be present during treatment may be needed for even the simplest procedure.
  43. 43. TASK Beginning of independence and of skill acquisition • Good outcome-capable and competent • Bad outcome –dependent and unsure
  44. 44. Development of initiative (3 to 6 years) • Continues to develop greater autonomy • Initiative is shown by physical activity and motion, extreme curiosity and questioning and aggressive talking. • A child is inherently teachable. One part in initiative is the eager modeling of behaviour of those whom he respects. • Opposite of initiative is guilt. In Erickson’s view child’s ultimate ability to initiate new ideas or activities depends on how he expresses without feeling guilty about expressing a bad idea or failing to achieve at what was expected.
  45. 45. TASK Successful pursuit of certain goals or aims • Good outcome-confident about skills • Bad outcome –hesitant ,uncertain
  46. 46. Mastery of skills (Age 7 to 11 years) • Child works to acquire the academic and social skills that allow to compete in an environment to achieve significant recognition. • In Erickson terms child acquires industriousness and begins preparation for entering into a competitive and working world. • Orthodontic treatment in this age group is likely to involve in wearing removable appliance.
  47. 47. TASK Acquisition of scholastic and social skills • Good outcome-literate, numerate and socially integrated • Bad outcome –failure to acquire scholastic skills ,socially isolated
  48. 48. Development of personal identity ( 12 to 17 yrs) • Adolescence, a period of intense physical development and psychosocial development • A unique personal identity is acquired. • Extremely complex stage because of many new opportunities like academic, responsibility and physical ability changes that arise • Orthodontic treatment is carried out during adolescence and behavioral management is challenging as parental authority is rejected, poor psychological situation if carried only because parents want them to undergo treatment.
  49. 49. TASK Clear sense of own individuality and of aims in life • Good outcome-suitable career choice, satisfactory heterosexual relationship • Bad outcome –uncertain of career, poor peer relationship
  50. 50. Development of intimacy (Young adult 19-25 yrs) • Develop an intimate relationship with others. successful development of intimacy depends on willingness to compromise and even to sacrifice to maintain a relationship. • Young adults seek orthodontic care to improve their appearance as this will facilitate intimate relationship. • Factors affecting intimate relationship are appearance, personality, emotional qualities, intellect.
  51. 51. TASK Establishment of satisfactory long term intimate relationship • Good outcome-stable relationships and good career • Bad outcome –poor intimate relationships and career choice
  52. 52. Guidance of the next generation (Adult 25-40yrs) • Major responsibility is establishment and guidance of next generation as supportive parent. • Other aspect is service to the group community and nation. Attachment of integrity (Late Adult 40+) • Final stage of psychosocial development with a combination of gratification with disappointment. • Feeling of integrity. • It is a feeling that one has made the best of life’s situation and peace with it. • The opposite characteristic is despair.
  53. 53. TASK Rear children in stable union • Good outcome-successful career , family stability • Bad outcome –poor career attainment , unstable relationships Acknowledgement of life’s successes and failures • Good outcome-acceptance of life’s limitations and vagaries • Bad outcome –despondency and despair
  54. 54. MERITS AND DEMERITS • Compelling and coherent account of development. Emphasis on the active interaction between the individual and the environment shaping the final outcome • Identity achieved at adolescence as the foundation for the main tasks, modes and conflicts of the subsequent life cycle • A major drawback is the lack of empirical evidence to support his conclusions.
  55. 55. HIERARCHY OF NEEDS Abraham Maslow 1954 • A classification of the individuals priority of needs and motivations during personality development • The needs are arranged in a hierarchy and as one need is satisfied another higher order need will emerge • Motivation is constantly required • Pain avoidance, tension reduction, pleasure acts as sources of motivation.
  56. 56. • Understanding the totality of the patient called self actualization • The ability to use ones capacities to good purpose to become fully absorbed in what one seems important, and to do so in a lively yet selfless manner. He consider a self actualized individual to be fully human.
  58. 58. Mahler’s theory (1933) • This theory categorizes the early childhood object relations to understand personality development. • The period of childhood is classified into three stages. -Normal autistic phase -Normal symbiotic phase. -Separation individualization phase.
  59. 59. Normal autistic phase (0-1 yr) • It is a state of half sleep, half-wakefulness • This phase involves achievement of equilibrium with the environment. Normal symbiotic phase (3-4 weeks to 4-5 months) • Infant at this stage is slightly aware of caretaker but they both are still undifferentiated.
  60. 60. • Separation individualization process (5-36 months) • This phase is divided into 4 sub phases. -Differentiation (5-10 months) -Practicing period (10-16 months) -rapprochements (16-24 months) -Consolidation and object constancy (24-36) Differentiation (5-10 months) -Infants are alert as cognitive with neurological maturation occurs -Characteristic stranger anxiety present during this stage. -differentiates between self and other.
  61. 61. Practicing period (10-16 months) • Beginning of phase by upright locomotion. • Child learns to separate himself from mother by crawling. • Separation anxiety is present, as the child still requires the mother for safety. Rapprochement (16-24 months) • Child becomes toddler aware of physical separateness. • Childs shows his mother newly acquired skills. • Mother’s efforts are not helpful resulting in temper tantrums. • Rapprochement crisis develops as child wants to be soothed (calm) by the mother but unable to accept her help. • Crisis resolves as the child’s skill improves
  62. 62. Consolidation with Object constancy (24-36 months) • Child achieves a definite sense of individuality and is able to cope up with the mother’s absence. • Feel comfortable when mother leaves but knows that she will return • Develops an improved sense of time and can tolerate delay.
  63. 63. CLASSICAL CONDITIONING Ivan Pavlov 1927 Based on stimulus reflex response ( an involuntary response to an external stimuli) When two events ,observed to occur together (proximity in time and space),will tend to be associated or paired together by the observer(pairing of initial and neutral stimuli).
  64. 64. The principles involved in these process are Generalization • Process of conditioning is evoked by a band of stimuli centered around a specific conditioned stimulus. Thus a test stimulus similar to training stimulus results in response. Extinction • If reinforcement does not occur results in extinction of the fear. Discrimination • It is opposite of generalization. If the child is exposed to clinical setting which are different, child learns to discriminate between the two clinics and even the generalized response to any office will extinguish.
  65. 65. PRINCIPLES • Developing good habits. • Breaking habits and elimination of condition fear • Psychotherapy, to decondition emotional fear • Developing positive attitudes • Teaching alphabets.
  66. 66. OPERANT CONDITIONING 1. Positive reinforcement • Occurs if a pleasant consequence follows the response e.g., a child rewarded for good behaviour following dental treatment. 2.Negative reinforcement • Involves removal of unpleasant stimulus following a response, e.g., if the parent gives into the temper tantrums thrown by the child, he reinforces this behaviour. 3.Omission • Refer to removal of the pleasant response after a particular response e.g., if the child misbehaves during dental procedure. If it’s favorite toy is taken away for short time resulting in the omission of the undesirable behaviour. 4.Punishment • Involves introduction of an aversive stimulus into a situation to decrease the undesirable behaviour, e.g., use of parental rake in correction of tongue thrusting habit.
  67. 67. Social learning theory Bandura (1963) proposed social learning theory . Thought to be the most complete. Clinically useful and theoretically a sophisticated form of behaviour therapy. Advantages • Less reductionistic • Provides more explanatory concepts. • Encompasses a broader range of phenomena.
  68. 68. • The learning behaviour affected by 4 principle elements. Antecedent determinants The conditioning is affected if the person is aware of what is occurring. Consequent determinants. Person’s perception and expectancy (cognitive factors) determine behaviour. Modelling Learning through observation eliminates the trial – error search. It is not an automatic process but requires cognitive factors and involves 4 processes which are • Attentional Processes • Retention processes • Reproduction processes • Motivational processes Self – regulation This system involves a process of self-regulation judgment and evaluation of individual’s responses to his own behaviour.
  69. 69. Oral theory of sears with wise (1950) • According to this theory strength of oral drive is in part of function of how long a child continues to feed by sucking. Thus it is not frustration of weaning that produce thumb sucking, but oral drive, which has been strengthened by the prolongation of nursing.
  70. 70. Benjamin theory (1960) • He says, “Thumb sucking arises from the rooting (or) placing reflex seen in all mammalian infants. Rooting reflex is the movement of the infant’s head and tongue towards an object touching his cheek. The object is usually the mother’s breast but may also be a finger (or) a pacifier. This rooting reflex disappears in normal infants around 7-8 months
  71. 71. Dunlop Beta hypothesis • He states that best way to break a habit is by its conscious, purposeful repetition. He suggests that the child should be asked to suck his thumb observing himself as he indulges in the habit. • This procedure is very effective if the child is asked to do the same at a time when he is involved in an enjoyable activity.
  73. 73. Factors influencing behaviour • Growth and development • Family and peer influences • Past dental and medical experiences • Dental office environment
  74. 74. Factors which affect child's behaviour in the dental office : • Under the control of the dentist • Out of control of the dentist • Under the control of the parents
  75. 75. Under the Control of the Dentist 1.Dental Clinic : • Dental office should be warm and simulate a homely environment. Healthy communication should be established. • A pleasant environment helps to relieve the child’s anxiety about the dental situation. • The operating environment should be made colorful and lively with posters, TV and videogames and separate waiting room for children. • It should have a separate exit and an entry door. • Appointment time should be kept short. Early morning appointments are preferable for children. Children should not be kept waiting for too long as they tend to become restless.
  76. 76. 2.Effect of dentist’s activity and attitude • The dentist should form a good impression on the child. • Should avoid jerky and quick movements • Should be fluent in his words and actions
  77. 77. Jenks in 1964 described six categories of activities by which the dentist can fasten or enhance co-operation in children. They are Data gathering and observation • This involves collecting the type of information about a child and his parents that are obtained by a formal or informal office interview or by written questionnaire. • Observation includes noting behaviour of the child as he steps into the dental office during history taking and while the dental procedure is being carried out.
  78. 78. Structuring • Refers to establishing certain guidelines of behaviour set by the dentist and his team to the child. So that the child knows what to except and how to react. He also prepares the child for each phase of the treatment in advance. Externalization • It is a process by which the child’s attention is focused away from the sensation associated with the dental treatment. Components of externalization --- distraction --- involvement • The objective is to interest and involve the child but at the same time not to let him into verbal or motor discharges which might interfere with the necessary procedure.
  79. 79. Empathy and support: • Empathy is the capacity to understand and to experience the feelings of another without losing ones own objectivity. The dentist should have empathy to the child’s feelings. This can be achieved by • Permitting the child to express their feelings without rejection and listening when they wish to talk. • Communicating to the child so that their feelings are understood. • Comforting the child when needed • Encouraging children when they show acceptable behaviour.
  80. 80. Flexible authority • Includes compromises made by the dentist to meet the needs of the particular patient. Education and training • A program that educates both parents and children should be implemented on what constitutes good health and which stimulates them to make behavioral changes necessary to achieve these goals.
  81. 81. 3. Effect of dentists attire • The previous stressful experience of the child, the dentist white attire. The mere presence of the white attire would evoke a negative behaviour. 4.Presence or absence of parents in the operatory • Mother’s presence is essential for a pre schoolchild, handicapped child etc. An older child does not require mother’s presence because of the emotional independence of these children.
  82. 82. 5.Presence of older sibling • Older sibling serves as a role model in a dental situation. This again depends on the age of the patient. A presence of an older sibling has • little effect on behaviour of a 3 year old patient • no effect in case of 5 year olds • most noticeable effect in case of 4 year olds
  83. 83. II. Out Of Control Of The Dentist 1. Growth and Development • Deficiency in physical growth, congenital malformation. As awareness of the deficiency increases it leads to psychological trauma due to the rejection by the society. • Mentally handicapped children who cannot react to the requirements and therefore variations in behaviour are encountered. • A very young child shows negative behaviour and the same response may be transformed to a positive behaviour, as the child grows older.
  84. 84. 2. Nutritional Factors • Intake of sugar causes irritable behaviour • Hypoglycemia causes criminal behaviour • Skipping breakfast leads to impaired performance • Nutritional deficiency affects the milestones of biological and cognitive development. 3. Past medical and dental experiences • Any past unpleasant dental experience is associated with high degree of uncooperative behaviour. Emotional quality of the past plays a near significant role than the number of visits.
  85. 85. 4. Genetics • Genetic influence is modified by the environment i.e. there should be a constant interaction between genetic programme of the child and environment for the psychological development of the child. 5. School environment • 50% of child’s development is affected by the school. The teacher & peers help to influence the behaviour of younger children and seniors become role models to juniors. 6. Socio-economics status • The higher group develop mostly normally as all necessary requirements are met adequately and they aid is normal psychologic development. On the other hand, they may become spoilt if they get everything they demand.
  86. 86. III. Under the control of the parents 1. Home environment • Home is the first school for the child. • The first place where the child learns how to behave. All the individuals at home influence the child’s behaviour but none so much as the mother. The mother child relationship has been described as one tailed. E.g. in case of a broken home the child may feel insecure, inferior and depressed. • Post natal behaviour of the child depends on the prenatal emotional status of the mother.
  87. 87. 2. Family development and peer influence • The position of the child, status of the child in the family & parental attitudes influence the child’s behaviour. Over indulgence can lead to exploit behaviour in the child who may show sudden out bursts and temper tantrums. • Internal family conflicts affect the behaviour as the child can sense disharmony and this can emotionally frustrate the child. • Sibling relationship influences the Childs behaviour. The younger child tries to follow the model of the older sibling and family member thus showing the same behaviour of sibling.
  88. 88. 3. Maternal Behaviour • Prenatal characteristics are unilateral & termed one tailed • Maternal influence on the children’s mental, physical and emotional development begins even before birth. • Somatic development of fetus depends on nutritional status of the mother. • Neurohormonal system of mother transfers emotion to the factors. • Postnatal behaviour of the child is linked to pre natal emotional status of the expectant mother. • Emotional stress during pregnancy can lead to an excessively active and irritable infant • Alcohol, smoking, keratogenic drugs affect the child’s development if consumed during pregnancy.
  89. 89. 4.Maternal influences on personality development • The mother–child relationship falls into two categories Autonomy VS Control Hostility Vs Love • Mothers who allowed enough autonomy & who expressed affection had children who were friendly & cooperative. Punitive mothers and those who ignored their children exhibited negative behaviour. 5. Maternal attitude & Childs behaviour • Over protective – shy, submissive, anxious • Overindulgent – Aggressive, demanding, temper tantrums • Under affectionate – usually well behaved, but unable to cooperate, shy & may cry easily. • Rejecting – Aggressive, overactive, disobedient • Authoritarian - Evasive & dawdling
  90. 90. Behaviour shaping: • Is the procedure, which slowly develops behaviour by reinforcing a successive approximation of the desired behaviour until the desired behaviour comes into being.
  91. 91. BEHAVIOUR MODIFICATION Defined as an attempt to alter human behaviour and emotion in a beneficial way in accordance with the laws of learning. Behaviour management classified as NON Pharmacological Pharmacological • Communication pre medication • Behaviour modification sedatives and hypnotics Desensitization anti anxiety drugs Modelling anti histamines Contingency conscious sedation Behaviour management general anesthesia
  92. 92. Communicative Management. • Used in both cooperative and uncooperative child (Chambers in 1976). • This is the basis for establishing a relationship with the child which allows successful completion of dental procedure and at the same time help the child develop positive attitudes towards dental care. • Means by which the dentist gets his point across by making himself understood by the use of expressions. • The communication should always be established from the first entry. • i.e. to the reception area.
  93. 93. • Type of communication: Verbal -> by speech Non-verbal -> (multi sensory communication) Both -body language Smiling Eye contact Showing concern By touching the child Giving him a pat Giving him a hug Expressing without speaking.
  94. 94. To Communicate ways: • Communication should be relaxed & comfortable • language that is chosen should contain words that express pleasantness, friendship and concern. – Verbal communication is best for children more than 3yrs of age. Voice that is used should be constant and gentle. Tone of voice can express empathy & firmness & support. – Content of the conversation should make the child feel that the dentist is his well-wisher. Conversation should include asking the child’s name, age, class and background. – Always the patient should be addressed by name. – Communication should be from a single source either between the dentist and the child or the child & dental assistant to avoid confusion. The child is very sensitive to expression changes – sitting and speaking at the eye level allows for a friendlier atmosphere. • - Communication is a multisensory process in the sense that it includes a transmitter, the spoken word is the medium and the pediatric patient is the receiver. • - Use of euphemism/substitute words can influence the behaviour. E.g. Anesthetic sol is referred to as water to put teeth to sleep ,radiograph as tooth picture.
  95. 95. Behaviour Shaping : Modification Involves three techniques • Desensitization • Modeling • Contingency management Desensitization : • Joseph wolpe in 1975 used this techniques to remove fears and tension in children who have had previous unpleasant experience. • It is accompanied by teaching the child a competing response such as relaxing and then introducing a threatening stimuli
  96. 96. Tell show do(TSD) Technique • Addleston in 1959 introduced the concept of TSD. • Tell & show every instrument & step and explain what is going to be done. • Continuously and in grades the procedure should be moved from the least fear promoting object to more fearful ones. • Indication for TSD: – 1st visit. – Subsequent visits when introducing new procedure – Fearful child. – Apprehensive child because of information received by peers or parents. • TSD techniques are applied as follows: • Explaining the procedure slowly and repeatedly by using the language or terms that the child can understand. The dentist demonstrates the procedure exactly as explained.
  97. 97. MODELLING • Bandura in 1969 introduced & develop from social learning principle procedure that allows a patient to observe one or more individuals (models) who demonstrate a +ve behaviour in a particular in situation. Therefore, the patient will frequently imitate the model’s behaviour when placed in a similar situation. Modelling can be done by • Live models – siblings, parents of child etc., • Filmed models • Posters • Audio - visual aids.
  98. 98. • Learning through modeling is effective when – observer is in a state of arousal – model has relatively more status and prestige – +ve consequences associated with models behaviour – ( improves the behaviour of apprehensive children who have had no past dental experiences. Klarman R 1980) • ADV: No additional equipment, personal or alterations in the dental routine are required.
  99. 99. CONTINGENCY MANAGEMENT Method of modifying the behaviour by presentation or withdrawal of reinforcers. • A +ve reinforcers: Henry W Fields in 1984. In this the contingent presentation increases the frequency of behaviour. • B –ve rein forcers: Stokes and Kennedy in 1980. In this, the contingent withdrawal increases the frequency of behaviour this is generally a termination of an aversive stimulus. • E.g. withdrawal of the mother.
  100. 100. • Types of reinforces can be: 1 social: eg praise, +ve facial expression, physical contact by shaking hand, holding & patting shoulder on the back 2 material: may be in the form of toys, games. 3. Activity reinforcers : involving the child in some activity like watching a T.V show /special programmer • For the contingency management social reinforces are the most effective.
  101. 101. Behaviour Management Audio analgesia: or “white noise” is a method of reducing pain. • This technique consists of providing a sound stimulus of such intensity that the patient finds it difficult to attend to anything else ( Gardner,licklider,1959). Auditory stimulus such as pleasant music has been to reduce stress and also reduce the reaction to pain.
  102. 102. 2. BioFeedback: (Buonomono 1979) • Involves the use of certain instruments to detect certain physiological processes associated with fear. • E.g. If B.P. is high, the instrument gives stimulation and subject is taught to control the signals, therefore it is useful in anxiety and stress related disorder.
  103. 103. 3. Humor : • Helps to elevate the mood of the child and this helps the child to relax Functions of humor. • Social : forming and maintaining relationship • Emotional: Anxiety relief in the child. • Information : Transmission of essential information in a non threatening way. • Motivation: increases the interest and involvement of the child. • Cognitive: Distraction from fearful stimuli.
  104. 104. 4. Coping: • The mechanism by which the child copes up with the dental treatment. • Lazaue in 1980 defined coping as the cognitive and behavioural effects made by an individual to master, tolerate or reduce stressful situation. • Pts under stress prefer to draw comfort or reassurance from an authority figure, thus establishing a close or trusting relationship with the dentist or dental assistant. 2 types of coping effects a .Behavioral: • Are the physical and verbal activities in which the child engages to overcome a stressful situation.
  105. 105. b. Cognitive • Child may be silent and thinking in his mind to keep calm. It enables the children to maintain realistic perspective on the events at hand (reality oriented working) • Perceive the situation as less threatening (cognitive re appraisal). • calms and reassures themselves that everything will be all right (emotion regulating cognition) [Sandra L Curry 1988]. Signal system • Is a method of coping suggested by Musslemann in 1991, the child is asked to raise his hand when it hurts. The normal coping system followed by the dentists to reduce tension & pain are friendliness, support & reassurance
  106. 106. 5 Voice control • It is the modification of intensity and pitch of one’s own voice in an attempt to dominate the interaction between the dentist and the child. • used in conjunction with some form of physical restraints and hand over mouth exercise change in tone from gentle to firm is effective in gaining the child’s attention and reminding him that the dentist is an authority figure to be obeyed. 6 Relaxation • Used to reduce stress and is based on the principle of elimination of anxiety.
  107. 107. 7 Hypnosis • Hypnosis is an altered state of consciousness characterized by a heightened suggestibility to produce desirable behavioral & physiological changes. • Romanson in1981 : One of the most effective non pharmacologic therapies used in children for a no. of different procedures. • Richardson in 1980 : when used in dentistry- hypnodontics or psychosomatic or suggestion therapy. 8 Implosion therapy • Mainly comprises of home, voice control & physical restraints
  108. 108. 9 Aversive Conditioning: • Safe & effective method of managing extremely negative behaviour. Common method - HOME -PHYSICALRESTRAINTS • Before using these techniques dentists should obtain prior permission from the parents ( Patricia Hagan 1984)
  109. 109. Home (Hand over mouth exercise) Introduced by Evangeline Jordan in 1920 Purpose: to gain attention of the child so that communication can be achieved. Indication: • A healthy child who exhibits defiance and hysterical behaviour during treatment. • 3 to 6 yrs old • Children displaying uncontrollable behaviour. Contra indications: • Child under 3 yrs of age. • Handicapped child immature /frightened children (physical, emotional, mental).
  110. 110. Several variations of home: • Hand over mouth with airway restricted & nose. • Towel held over the mouth only. • Dry towel held over the nose & mouth. • Wet towel held over the nose & mouth.
  111. 111. Homar (airway restricted): • Adv: child will be quiet so as to breathe and the screaming will decrease as that the doctor can proceed. • Together with hand over mouth the nostrils are pinched for 15 secs. • Belanger in 1993 as airway restriction was the critical element it should be avoided.
  112. 112. Physical Restraints • Last resort for handling uncooperative/handicapped patients • Kelly in 1976 suggested that restraints are generally needed for children who are hyper motive, stubborn or defiant. • The child is seated in the mother’s lap and one of the mother’s hand is placed on the child’s forehead while the other hand is placed on both the child’s wrists. • Physical restraints involve restriction of movement of the child’s head, hands, feet or body. It can be 1 active – restraints performed by the dentist or the dental assistant without a restraining device. 2 passive – with the aid of restraining device.
  113. 113. Type of restraints: • For the body – Pedi wrap, papoose board, sheets, bean bag with strap, towel and tapes. • For extremities – Velcro straps, posey straps, towel& tape. • For the head - Head positioner, fore arm body support. • For the mouth – mouth blocks, banded tongue blades. Mouth props: They are used at the time of L A to prevent child from closing his mouth. Also used for handicapped child. • Child who cannot keep the mouth open for a long time. • Child becoming extremely fatigued due to long appointment
  114. 114. Relating emotional maturation to the dental situation Two years old: • This age also referred as the terrible two. At 2 yrs of age their ability to communicate is very less as vocabulary at that age range from 12 to 1000 words only. The 2 yr child is often referred to as being in the pre-cooperative stage. Solitary play is preferred as the child has not learned to play with other children . The child is too young to be reached with words alone & must handle & touch objects slowly in order to grasp their meaning fully. • The young child fears falling or sudden unexpected movements. Suddenly being lowered or tilted back in the dental chair without warning can cause fear. Quick jerky movements of the hands are frightening. Separating the young child from the parent is extremely difficult & the 2 yrs old should be accompanied by parent to the treatment room.
  115. 115. Three years old: • It is easier & 3 yr olds communicate better with the dentists. They have a great desire to talk and often enjoy telling stories to the dentist. At this stage the dental personnel makes a positive approach with the child. It is better to speak positively to this child, as they are apt. to do things they are asked not to. Four Year Old: • The 4 yrs old usually listens with interest to explanations and is normally responsive to verbal directions. He is generally a good dental patient. In some situations, they become defiant. Fear of strangers is lessened by the age of four-.the prick of hypoderm or sight of blood following tooth extraction may produce a reaction disproportionate to the degree of pain.
  116. 116. Five Year Old: • The 5 yr old has reached an age of readiness to accepts group activities and community experiences. A 5 yr old properly prepared by the parents has little fear of being separated from the parents for the dental appointment. The children in this age group are usually proud of their possessions and to establish a good rapport. A +ve appreciative comment about clothes is an effective method. Six to twelve Years old: • In the period from 6 to 12 yrs of age the child learns about the outside world & become increasingly independent of the parents. These are years when closely, knit group are formed and they are important years to teach how to get along with people and abide by the rules of the society • The child at this age can generally resolve fears of the dental procedures because the dentist can use reason and explain what is being done. The child also has learned to tolerate unpleasant situations and hand marked desires to be obedient, carrying frustrations well.
  117. 117. Thank you For more details please visit