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Child psychology


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Child psychology

  2. 2. Contents • Introduction • Theories of Emotional Development - Psychodynamic theories - Behaviour learning theories • Application of child Psychology in dental practise • Psychological management of child behaviour. - Factors effecting child behaviour - Classifications of child behaviour
  3. 3. Contents • Emotional Development and Its Relation to cooperation in Treatment • Patient compliance • Behaviour management of child
  4. 4. Contents • Practical psychology to clinical practise in orthodontics - social psychology of Orthodontics - Orthodontic motivational psychology - Educational psychology • Management of an adolescent patient • Psychology – Orthognathic surgery • Conclusion • References
  5. 5. Introduction • The successful practice of orthodontics is significantly dependent on the interaction between the orthodontist and the patient. • It requires active cooperation from the patient throughout the necessary lengthy orthodontic procedures.
  6. 6. • In the practice of orthodontics today, time invested in creating and maintaining the important patient-doctor bond. • Orthodontist behaviors such as listening, empathy, and explanation are important in achieving that goal.
  7. 7. Definitions • PSYCHOLOGY: is the science dealing with the human nature, function, and phenomenon of his soul in the main. • In Greek, - Psyche – mind - Logos - study • CHILD PSYCHOLOGY: is the science that deals with the mental power or an interaction between the conscious and sub conscious element in a child.
  8. 8. • BEHAVIOR: is any change in the functioning of the organism. ( or ) is an observable act, it is defined as any change observed in the functioning of an organism. • BEHAVIOR MODIFICATION: (Mathew son) it is the attempt to alter human behavior and emotion in a beneficial manner according to the laws of modern learning theory. • Psychologist A person who is specialized in the study of the structure and function of the brain and related mental processes of animals and humans.
  9. 9. Theories of child psychology
  10. 10. • These theories can be classified into 2 major types. I. Psychodynamic theories. II. Behavior learning theories. • Psychodynamic theories : The study of the forces that motivate behavior. 1. The archaic discharge syndrome - Sigmund Freud 2. The psycho-analytic theory - Sigmund Freud 3. The psycho-social Theory – Erik Erickson. 4. The theory of Hierarchy of needs – Abraham Maslow.
  11. 11. II Behavior learning theories: 1. The classical conditioning theory Ivon pavlov 2. The operant conditioning theory – Skinner. 3. The cognitive development theory – Jean Piaget. 4. The social learning theory – Albert Bandura
  12. 12. PSYCHODYNAMIC THEORIES 1. Archaic discharge syndrome: This theory was put forward by the ‘Father of Modern Psychiatry” i.e., Sigmund Freud (1939)
  13. 13. • It suggests that the human body contains 2 types of neurons. - psi neurons – For storage of emotions. - phi neurons – for conduction of emotions. • When the stored emotion reach a certain level, a discharge is sparked off leading to an overt display of emotions.
  14. 14. 2. Psycho-analytic Theory: defined as “a theory which provides a comprehensive approach to understanding of psychic development, emotions and behavior as well as psychiatric illness” • Freud hypothesized 3 structures in this theory for the understanding of inter psychic process and personality development. The parts of the psychic apparatus are • ID • EGO • SUPEREGO
  15. 15. • Personality dynamics and levels of consciousness
  16. 16. Id • Primitive , instinctive component of personality • Pleasure principle • It is the matrix within which the ego and superego become differentiated • Unconscious drives for pleasure and destruction • Urge to eat, sleep, defecate and copulate • true psychic reality
  17. 17. Ego : Executive of the personality • The Id is bridled and managed by the Ego • The ego is conscious and reality oriented • The Ego delays satisfying Id motives and channels behavior into more socially acceptable outlets • It keeps a person working for a living, getting along with people and generally adjusting to the realities of life
  18. 18. • Ego works “in the reality principle” • Uses secondary process thinking • The main aim of realistic thinking is to prevent the discharge of tension until an object that is appropriate for satisfaction of the need has been discovered • The ongoing tension between the insistent urges of the Id and the constraints of reality help Ego develop more and more sophisticated thinking skills
  19. 19. Super ego: Judicial branch of personality • It is derived from familial and cultural restrictions placed upon the growing child • Contains moral lessons and values • Conscience- moral prohibitions against certain behavior especially expressing the sexual and aggressive drives of the Id • Ego ideal - image of what one ideally can be and how one ought to behave
  20. 20.
  21. 21. • Psycho-sexual theory : • Depending on the basic constrains of ID, ego and super ego, Freud defined 5 stages of development based on the “energy” or “Drive theory”. • According to this theory through out each of the psycho- sexual stages, specific erotogenic body zones, when stimulated, give rise to erotic pressure or libido.
  22. 22. • The 5 stages are, • Oral stage ( birth to 18 months ) • Anal stage ( 18months – 3 years) • Phallic stage or oedipal stage ( 3-5 years ) • latency stage ( 6- 11 years ) • Genital stage ( 11 years onwards )
  23. 23. Oral Stage -characterized by passiveness & dependency- primary zone of pleasure- oral region • Hunger is satisfied by oral stimulation • Thumb or any other object is put into the mouth for gratification • Digit sucking habit in older individuals- shows some form of dependency
  24. 24. Anal stage- ages 1-3yrs-marked by egocentric behavior • Anal zone- primary source of pleasure • Gratification-derived from withholding or expelling faeces • Over emphasis on toilet training- makes an obstinate or perfectionist personality • Very less emphasis-results in impulsive personality
  25. 25. Phallic stage-3-6 yrs- the awakened sexual impulses are directed towards parents of the opposite sex  Males- ‘Oedipus complex’, ‘Castration complex’  Females- ‘Electra complex’
  26. 26. The Oedipus complex
  27. 27. The Electra complex
  28. 28. Latency period-6-12yrs -period of consolidation. all attention is turned to skills that are needed to cope with the environment. Superego is firmly internalized. Genital stage -begins with puberty Characterized by ego’s struggle to gain mastery and control over the impulses of id and perfection of super ego Fluctuating extremes between the emotional behaviors predominate.
  29. 29. Psychosocial theory • Erik Homburger Erikson Development of basic trust: • Oral stage of Freud’s theory • Basic trust Vs Mistrust
  31. 31. Development of Autonomy Basic conflict (Autonomy vs shame or doubt) • Moving away from the mother and developing sense of individual identity or autonomy • Takes pride in new accomplishments and wants to do everything for themselves as they learn to eat food, walk, talk, use toilets etc
  32. 32. • Conflicts with siblings, peers and parents • Consistently enforced limits on the behavior are needed to allow the child to develop trust in a predictable environment
  33. 33. Principle anxiety- Fear of loss of love Fear of separation “From a sense of self-control without a loss of self-esteem comes a lasting sense of good will and pride; from a sense of loss of self- control and foreign over control came a lasting propensity for shame and doubt”
  34. 34. Development of initiative: Stage -3 early childhood – 3-6 years • Develop motor skills and become more engaged in social interaction with people around them • The initiative is shown by physical activity and motion, extreme curiosity and questioning, and aggressive talking
  35. 35. • “I will try” • It is time for them to learn how to achieve a balance between the eagerness for adventure and responsibility, and also to control impulses and childhood fantasies • The primary fear – ‘Fear of Bodily Injury’ • Imaginative & uninhibited plays - important
  36. 36. Behavior during dental treatment • First dental visit • Success in coping with anxiety of visiting the dentist can help develop greater independence and produce a sense of accomplishment • If poorly managed, a dental visit can result in sense of the guilt that accompanies failure
  37. 37. Mastery of skills Stage 4 – Elementary and Middle school years 6-11years • Develop feelings that they can make things, use tools, and acquire skills and a sense of “I am capable” develops
  38. 38. Behavior during dental treatment  Orthodontic treatment  Behavioral guidance is done in this stage by clearly outlining the child, what to do or how to behave and then reinforcing it positively  Because of the child’s drive for a sense of industry and accomplishment, cooperation with treatment can be obtained
  39. 39. Development of Personal identity Stage 5 – Adolescence(12 -17years) • Maturation is seen mentally and physiologically • Emerging sexuality complicates relationships with others, at the same time, physical ability changes, academic responsibilities increase, and career possibilities begin to be defined
  40. 40. Behavior during dental treatment • Most orthodontic treatment • A poor psychological situation is created by orthodontic treatment if it is being carried out primarily because the parents want it, not the child • External motivation is from pressure from others – peer group • Internal motivation is provided by an individual’s own desire
  41. 41. Development of intimacy: Stage 6 – young adult- 18-35 years • Love relationships • Successful development of intimacy depends on a willingness to compromise and even to sacrifice for the sake of maintaining a relationship
  42. 42. Guidance of next generation Stage 7- Middle Adulthood- 35-65 years Virtue of care Positive outcome • Child caring • Teaching • Help next generation Negative outcome • Self centered
  43. 43. Stage 8 – Late Adulthood- 65 – death Basic conflict- Integrity vs. Despair Description • Old age is a time for reflecting upon ones own life and seeing it filled with pleasure and satisfaction or disappointments and failures Positive outcome • Accept death in a sense of integrity Negative outcome • Despair and Fear death
  44. 44. Application of psychodynamic principles to clinical practice Model Dentist’s role Patient’s role Clinical application of model Proto type of model Activity- passivity Does something to patient Receives the treatment Operative dental treatment Parent to child Guidance cooperation Tells patient what to do Obeys accordingly Dental check up appointments Parent to child Mutual participation Advises and negotiates with patient Patient in equal partner care Negotiation of treatment or preventive plans Adult to adult Three basic models of dentist – patient interaction Craig D. Woods CDA Journal,Vol 35(3), P No: 186-191, March 2007
  45. 45. Application of psychodynamic principles to clinical practice • Mother – child Competent mother-child Behaves in a consistent manner Sets limits and controls child’s behaviour Positive emotional interactions with child and Containment of child’s fears and anxieties Nurtures and encourages child’s independence and social skills Aggressive mother-child  Behaves in an inconsistent manner, few limits or boundaries set for the child’s behavior  Overly attentive or inattentive and emotionally inclusive or emotionally distant children Children exhibit negative and controlling behaviors, mothers respond in an inconsistent and/or aggressive manner Anxious mother-child Behaves in authoritative manner  Negative and punitive  Strict limits and controls on the child and inhibit the child’s autonomy and social skills
  46. 46. COGNITIVE DEVELOPMENT Cognition - “knowing and understanding” • Mental processes by which knowledge is acquired, elaborated, stored, retrieved, and used to solve problems • Attending, perceiving, learning, thinking and remembering Cognitive development - changes that occur in children’s mental skills and abilities over time
  47. 47. “The principle goal of education is to create men who are capable of doing new things, not simply of repeating what other generations have done -- men who are creative, inventive and discoverers” Adaptation is achieved by • Assimilation – Incorporation of new information into existing knowledge • Accommodation –Adjusting of schemes to fit new information and experiences
  48. 48. Stages of cognitive development
  49. 49. “Sensorimotor” • Infants first begin to learn through sensory observation and gain control of their motor functions through activity of exploration and manipulation of the environment • At the end of sensory motor stage, two year olds can produce complex sensory motor patterns and use primitive symbols Crider AB Cognitive Development P No: 350-355,3rd Edition
  50. 50.  Simple reflexes - Rooting reflex , sucking reflex  First habits and primary circular reactions  Secondary circular reactions  Coordination of secondary circular reactions  Tertiary circular reactions, novelty and curiosity
  51. 51. Stages of cognitive development Sensorimotor period ( 18-24 months )
  52. 52. • Stage of preoperational thought ( 2-7yrs) • In this stage the children begin to represent the world with words, images and drawings • Stable concepts are formed, mental reasoning emerges and magical beliefs are constructed • At this stage ,capabilities for logical reasoning are limited.
  53. 53. Piaget’s Liquid conservation problem
  54. 54. Orthodontic/dental management  Animism can be used to the dental team’s advantage by giving dental instruments and equipment life like names and qualities. eg. Whistling Willie  Mr Thumb  Maintainence of oral hygeine – ‘Brushing your teeth makes them feel smooth’ ‘Toothpaste makes your mouth taste good’
  55. 55. Limitations of preoperational thought Centration • Focus on one aspect of situation, neglecting other important features • Children are easily distracted by their perpetual appearance of objects Irreversibility • The ability to go through a series of steps in a problem and then mentally reverse direction, returning to the starting point • Child of preoperational thought lacks this reversibility
  56. 56. Stage of concrete operations (7-11 yrs) • Child operates and acts on the concrete and real perceivable world of objects and events • During this period the child begins to understand logical concepts • The child no longer makes judgement solely on the basis how things appear • They develop the quality of Reversibility
  57. 57. Classification/ Categorization Able to classify the things and consider their relationships Items are categorized simultaneously along two independent dimensions shape and colour
  58. 58. Conservation • Able to pass conservation tasks and provide clear evidence of operations • The conservation tasks demonstrate a child’s ability to perform concrete operations • allow children to coordinate several characteristics rather than focus on a single property
  59. 59. Stage of formal operations (11 yrs- Olders) • The person’s thinking operates in a formal, highly logical, systemic and symbolic manner • The stage of formal operations is characterized by the young person’s ability  To think abstractly  To reason deductively  To define concepts
  60. 60. MASLOW’S HIERARCHY OF NEEDS Systematic arrangement of needs according to priority, which assumes that basic needs must be met before less basic needs are aroused • Maslow said that most of the people want more than they have • “As one desire is satisfied, another pops up in its place"
  61. 61. • Maslow created a hierarchy of needs as a pyramid
  62. 62. BEHAVIOUR LEARNING THEORIES • Classical conditioning theory - Ivan Pavlov • Operant conditioning theory - B.F.Skinner • Social learning theory - Albert Bandura
  63. 63. Classical Conditioning Theory Ivan Pavlov (Sep 14th 1849 – Feb 27th 1936)
  64. 64. “Learning by Association” or Classical Conditioning • Learning that result from association or pairing of two stimuli in the environment • Classical conditioning is a type of learning in which a stimulus acquires the capacity to evoke a response that was originally evoked by another stimulus
  65. 65. Pavlov’s famous dog experiment
  66. 66.
  67. 67. Pavlovian concept of accommodation in biological systems  Conditioning  Reinforcement  Habituation
  68. 68. • Classical conditioning is seen to occur readily in young children
  69. 69. • Strengthening of the conditioned behavior If the conditioned association is strong- takes many visits to establish co-operation • Extinction-if the unconditioned stimulus is not reinforced 4 important concepts-
  70. 70. • Generalization - if the child has had a bad experience in some other doctor’s office • Discrimination - steps taken to change the office settings- child differentiates
  71. 71. B. F Skinner Operant conditioning
  72. 72. • Operant conditioning- (B.F.Skinner) viewed conceptually as a significant extension of classical conditioning. • Operant conditioning differs from classical conditioning in that the consequence of behavior is considered as a stimulus for future behavior. This means that the consequence of any particular response will affect the probability of that response occurring again in a similar situation.
  73. 73. • In Classical conditioning- stimulus leads to a response- in Operant- the response is a further stimulus
  74. 74. • 4 basic types of operant conditioning distinguished by the nature of the consequence.
  75. 75.  Positive reinforcement: - If a pleasant consequence follows a response, the response has been positively reinforced. eg:- If a child is given a reward for such as a toy for behaving well during her first dental visit, he/she is more likely to behave well during future dental visits and the behavior was positively reinforced.  Negative reinforcement:- involves the withdrawal of an unpleasant stimulus after a response. eg:- a child who views a visit to the dental clinic as an unpleasant experience may throw a temper tantrum at the prospect of having to go there.
  76. 76. • Omission or Time out: - Involves removal of a pleasant stimulus after a particular response. • Eg:- If a child whose favorite toy is taken away for a short time as a consequence of a misbehavior probability of similar misbehavior is decreased. • Punishment:- This occurs when an unpleasant stimulus is presented after a response. This also decreases the probability that the behavior that prompted punishment will occur in the future.
  77. 77. • One mild form of punishment that can be used in children is “Voice Control”. Voice control involves speaking to the child in a firm voice to gain his or her attention, telling him that his present behavior is unacceptable and directing him as to how he should behave. • Operant conditioning can be used to modify behaviors in individuals of any age and it forms the basis for many behavioral patterns of life.
  78. 78. Hand over mouth exercise • 1920 – Dr Evangeline • 1947 - Levitas
  79. 79. Albert Bandura Obsevational Learning/modelling Theory
  80. 80. OBSERVATIONAL LEARNING (Modeling):- This behavior is acquired through imitation of behavior observed in a social context. There are 2 distinct stages in observational learning. Acquisition of the behavior by observing it. Actual performance of the behavior Children are capable of acquiring almost any behavior that they observe and that is not too difficult for them to perform at their level of psychical
  81. 81.  Whether a child will actually perform an acquired behavior depends on several factors like characteristics of role model. If the model is liked or respected the child is more likely to imitate them eg:- for adolescents the peer group are the major source of role models.  The young child observes an older sibling-most likely to imitate his behavior  Mother –important role model- her anxiety reflects on the child
  82. 82. Observational learning can be used to advantage in the design of treatment areas. Sitting in one dental chair, watching the dentist work with some one else in an adjacent chair can provide a great deal of observational learning. Both children and adolescents do better, it appears if they are treated in open clinics and observational learning plays an important part in this.
  84. 84.  Interpersonal relationships –affect the child’s behavior  Parent-child relationship - most intimate -most important in determining the emotional development  Parental attitude – can determine if the child will be hostile, co- operative or rebellious.
  85. 85.  Parenting Styles: – Baumrind (1967, 1971, 1980): 2 dimensions of parenting: • permissive-demanding dimension • accepting/rejecting dimension – 4 styles of parenting: • Accepting-permissive • Accepting-demanding • Rejecting-permissive • Rejecting-demanding
  86. 86. Over protective  Child not allowed to use his own initiative- assistance is forced upon .  Maternal overprotection- over-indulgence or extreme dominance  Children are usually shy, submissive & fearful- generally co-operative  Dentist has to break through shyness barrier for effective communication with the patient
  87. 87. Rejection  May vary from mild indifference to complete rejection  Mildly indifferent parents- child-feels inferior or neglected  They are unco-operative & don’t trust anyone easily  In extreme form-the children may be treated with scorn or even abuse
  88. 88.  As the children lack love & affection-they lack self –esteem & have deep anxieties  Suspicious, disobedient & aggressive  Should be dealt with a lot of attention & kindness- their demands should be respected as much as possible
  89. 89. Over anxious  Undue concern for even minor illness  Exaggerate the problem & excessive concern about the treatment  The child- very shy, timid  Dentist has to patiently overcome the fears of the child & the parent
  90. 90. Domination  Excessive demand from the parents- often criticizing the child and giving responsibility incompatible for the age  Child- resentful & negative  The dentist has to instill confidence in the child
  91. 91. Identification Parents try to relive their own lives through their children  If children don’t respond favorably-parent shows overt disappointment  The child lacks confidence & attempts very few things -afraid of failure  The dentist has to instill confidence in the child
  92. 92.  Fear and its management in children  behavior rating scales Wrights scale Frankel’s scale Lampshires classification  Psychology of habits
  93. 93. FEAR  It is a primitive response  In adults-this emotion is controlled though rationalization, in young children –it is very difficult  Types of fear- 1. Objective 2. Subjective
  94. 94. Objective fear -produced by direct physical stimulation  These fears are –felt ,seen ,smelt or tasted & found disagreeable by the child  If a child has been handled poorly previously by a dentist or doctor-develops a fear for future treatment  The doctor has to work slowly to re-establish the child’s confidence
  95. 95. Subjective fear - Fear based on feelings suggested to the child by others without the child having experienced it personally  Child- prone to suggestions-especially observes the parents- if parents display fear for treatment themselves-child develops unfounded fears  Most difficult to eradicate  Extra effort to familiarize the child slowly to various procedures & the office itself
  96. 96. Orthodontic/dental management  The fear & the way the child handles them – changes with age  Sleepy children-may be more fearful-less ability to rationalize- keep major appointments in the mornings  Intelligent children- more fearful as they have a greater awareness of danger- must give proof to them about the painlessness of the procedure  Orthodontics- by this age the child has improved ability to resolve fears
  97. 97. BEHAVIOR RATING SCALES  The orthodontist should recognize & categorize the child’s behavior so that he can manage the patient better  Scales - o Wright’s behavior rating scale o Frankl’s behavior rating scale o Lampshire’s behavior rating scale
  98. 98. Wright’s classification- 1. Co-operative 2. Lacking in co-operative ability 3. Potentially co-operative o Uncontrolled o Defiant o Timid o Tense co-operative o Whining
  99. 99. Wright’s classification- 1. Co-operative Child is relaxed, minimal apprehension When right approaches such as tell- show –do etc is used –positive reinforcement occurs
  100. 100. Lacking in Co-operative ability-  Some situations communication cannot be established-either patient is very young or has some disability  Children require special management- otherwise will tend to be un co- operative
  101. 101. Potentially co-operative -children with a behavior problem- but is capable of good behavior Sub categories- A) Un controlled - throws a tantrum an cries loudly -Shows the child is acutely anxious B) Defiant – controlled refusal to co-operate - usually very stubborn Seen in adolescents- refuses treatment suggested by the parents-passive resistance- shows their expression of freedom of choice for treatment The dentist should have a confident and structured approach to behavior Should not impose any treatment if not necessary
  102. 102. C) Timid- resorts to stalling tactics-very shy and tries to hide or runaway A slow & low key approach to build the child’s confidence is required Good communication- must be established D) Tense- co-operative accepts treatment without exhibiting overt resistance Manifests several body signs- trembling, wringing of hands Encouragement, tell-show-do work for such patients
  103. 103. E) Whining – Constantly whines & complains but allows the dentist to work Ignore the child’s behavior No response -stops the noise
  104. 104. Frankel behavior rating scale  Definitely negative  Negative  Positive  Definitely positive
  105. 105. Lampshire behavior rating scale  Co-operative  Tense co-operative  Outwardly apprehensive  Fearful  Stubborn/defiant  Hyperactive  Handicapped  Emotionally immature
  106. 106. BEHAVIOUR MANAGEMENT OF CHILD 1. Non-pharmacological (psychological approach) 2. Pharmacological • Non- pharmacological: 1. Communication 2. Behavior shaping (modification) • Desensitization • Modelling • Contingency management
  107. 107. 3. Behavior management • Audio / video analgesia • Biofeed back • Voice control • Hypnosis • Humor • Coping • Relaxation • Implosion therapy • Aversive conditioning.
  108. 108. • Pharmacological: 1. Pre-medication • Sedatives And Hypnotics • Anti-anxiety Drugs • Anti-histamines 2. Conscious sedation 3. General anesthesia.
  109. 109. Habit correction (AJO-DO 1979 Nov – Jacobson) • Two main schools of thought prevail : • The psychoanalysts regard the habit as a symptom of emotional disturbance, • Behaviorists view the act as a simple learned habit with no underlying neurosis. • Thumb-sucking in the schoolchild (6 to 12 years) is usually a manifestation of a general emotional and social immaturity.
  110. 110. • In treating habits in this age group, it is necessary to determine whether the habit is "meaningful" or ''empty.“ • If the sucking habit is one of a galaxy of symptoms of an abnormal behavior problem, a consultation with a psychiatrist is the first consideration. The habit in these instances would be regarded as ''meaningful."
  112. 112. SOCIAL PSYCHOLOGY • Why patient’s seek orthodontic treatment  • Adolescents : my mom thinks I need braces, to look better • Adults : own initiative; to improve facial appearance.  Clearly a person’s dento facial appearance can have a significant effect on their overall quality of life.
  113. 113. • “WHY DO PEOPLE WANT TO LOOK BETTER” • Adams suggested 1. Physical attractiveness stimulates differential expectations toward another. 2. An individual’s attractiveness appears to elicit differential social exchanges from others. 3. An important developmental outcome results from this social exchange. 4. Attractive people are more likely to manifest confident interpersonal behavior patterns than lesser attractive individual.
  114. 114. DEVELOPMENTAL PSYCHOLOGY OF ORTHODONTICS: • SHAW et al • BENEFIT OF SOCIAL PSYCHOLOGIC WELL BEING IN TERMS OF THREE SUB GROUPS: 1. Nick names and teasing. 2. Evaluation of dental appearance and social attractiveness. 3. Self esteem and popularity.  Concluded that when personal dissatisfaction with dental appearance is felt in childhood, it might well remain for a life time.
  115. 115. Patient Compliance • The success of orthodontic therapy frequently depends on patient compliance. • EGOLF and others described a compliant patient as one who practices good oral hygiene, wears appliances as instructed without abusing them, follows an appropriate diet, and keeps appointments.
  117. 117. • UNDERSTANDING THE ADOLESCENT PATIENT: • Peterson and Kuipers described adolescence as a period in life between childhood and adulthood when considerable change is occurring. • Under standing adolescent development can allow the orthodontist to help overcome obstacles in treating patients in this age group.
  118. 118. • MOTIVATING THE ADOLESCENT PATIENT: • “COOPER and SHAPIRO” Features of adolescent behavior used to ascertain a particular behavior. 1. Adolescents are concerned with self-image and identity, which can be useful in motivating them. 2. Independence and autonomy are important to an adolescent therefore achieving an adult like status could motivate the adolescent. 3. Peer relationships are important, so this feature motivate behaviors that meet social needs.
  119. 119. • They suggested that more successful motivation can be accomplished by individualizing the patient and recognizing adolescent values and issues. • The orthodontist should understand that adolescents are not influenced strongly by health specific goals.
  120. 120. EDUCATIONAL PSYCHOLOGY • One of the most promising areas of current research in patient cooperation is the area of educational psychology.
  121. 121. Educational psychological principles • Progressions(segmenting the skill to be learned into a number of simple and sequential component parts, or progressive steps) • E.g.,cervical headgear inserting for first time • Backward chaining(is the educational principle that incorporates stages, or progressions, into learning, only in reverse sequence). • E.g., patients first learn to remove elastics and retainers before they learn to place them. Donald J. Rinchuse, The use of educational-psychological principles in orthodontic practice.( AJODO 2001;119: 6:660-664)
  122. 122. Educational psychological principles • Shaping (close approximation): The behavior that is reinforced is the closest approximation of the ideal (or desired) behavior that the learner can make at that point in time.e.g., oral hygiene maintainance – small improvement – rewarding . • Reframing (symptom prescription, reverse psychology): Reframing is the psychological technique in which a behavior that is considered undesirable but pleasurable is made to appear, or reframed, as a duty.e.g.,Digit sucking ( all fingers and asking to make a list of times) Donald J. Rinchuse, The use of educational-psychological principles in orthodontic practice.( AJODO 2001;119: 6:660-664)
  123. 123. • Reinforcement theory: The overriding principle of reinforcement theory is to give more praise than criticism.It has been suggested that at least 3 words of praise be used for every word of criticism • Hypnosis: can be used for fearful and apprehensive patients. Clinical situations in which hypnosis or a closely related technique could be used are: impression making, bonding, debonding, and extraction of very loose deciduous teeth.
  124. 124. • O’Connor reported that impressions ranked fifth for “fears and apprehensions prior to orthodontic treatment,” and fourth for “greatest dislikes during treatment.”
  125. 125. • Kinesthesia( muscle memory) lacking manual dexterity • Learning by doing: Donald J. Rinchuse, The use of educational-psychological principles in orthodontic practice.( AJODO 2001;119: 6:660-664) I hear and I forget; I see and I remember; I do and I understand.
  126. 126. The learning styles inventory developed by KOLB, 4 learning styles. 1. ACCOMODATOR 2. DIVERGER 3. ASSIMILATOR 4. CONVERGER. Concrete experience Accommodator Diverger Reflective observation Assimilator Abstract conceptualization Converger Active experimentation
  127. 127.
  128. 128. • ACHIEVING PATIENT COMPLIANCE: • ROSEN provided a practical patient-oriented approach to creating a compliant patient. • Health care providers should develop a compliance model that is patient-centered rather than clinician-centered.
  129. 129. • WHITE suggested 1. Use the simplest appliance necessary to achieve treatment objectives with forces that are continuous and of low magnitude. 2. Prescribe analgesics when needed. 3. Expedite treatment time. 4. Let the fees reflect the challenges of a difficult patient.
  130. 130. CREATING A COMPLIANT PATIENT (MELVIN MAYERSON, “WICK” ALEXANDER JCO 1996 Sep) • Patient Education • Patient Motivation • Office Environment • Communication Techniques • Monitoring Progress
  131. 131. Patient Education • They need to know the costs and benefits of treatment, in time, money, and effort. • Patient education booklets, used to reinforce instructions throughout treatment, are written in positive tone to encourage and motivate patients.
  132. 132. Procedures and appliances explained to patient by Dr. Wick Alexander before treatment. INFORM BEFORE WE PERFORM
  133. 133. • Patient Motivation • WILLIAM JAMES “The most important discovery of the 20th century is that the attitudes of an individual can change”. • The only truly motivational technique is self-motivation
  134. 134. Office Environment • Every office reflects the personality of the orthodontist. • The goal is to maintain a friendly, warm, caring, professional atmosphere in which patients know that they will receive the highest- quality treatment.
  135. 135. Communication Techniques • An effective communication technique is to look in their eyes before you look in their mouths. • "Horizontal communication": Dr. J. Moody Alexander looking in patient's eyes before looking in the mouth. • Good communication should be honest as well as two-way, the orthodontist should be “askable”
  136. 136. Monitoring Progress • Each patient’s progress must be monitored constantly to maintain motivation and compliance throughout treatment. • When improvement is seen, praise the patient and share the achievement with the parent. • If slow progress is due to non-compliance, it is crucial that the patient and parents be informed as early as possible in a “mini-consultation”.
  137. 137. Methods of improving patient compliance (A.O. 1998 No. 2, T. Mehra, R.S. Nanda, P.K Sinha.)  Verbally praising the patient,  Discussing treatment goals and poor patient cooperation with the patient and parent.  Educating the parent about the use of orthodontic appliances, and about the consequences of poor compliance.
  138. 138. Special considerations for adults • Invisible orthodontic appliances. • Tooth colored brackets, fixed lingual appliances • Separate treatment area for adults or in a open area for interacting with other patients. • Orthognathic surgery.
  139. 139. PSYCHOLOGY – ORTHOGNATHIC SURGERY Psychological impact- • Some patients are under prepared for change in appearance. • some were surprised by the degree of reaction of others to the results. • further surprised by the amount of change they subsequently realized in their own attitudes and personality.
  140. 140.  Pre operative counseling with patients, relatives, and friends.  The importance of detailed preoperative discussions is very evident in this series of patients. These discussions must cover technical aspects of treatment and inconveniences that the patient will encounter during treatment.
  141. 141. ACHIEVEMENTS THROUGH ADHERENCE BY PATIENT : (compliant patient) • Achieve the treatment objectives in minimum treatment time.  Reduction of expenses involved in orthodontic treatment.  Improved oral hygiene can minimize damage to the periodontal tissues, limit the deleterious effects of decalcification, and even frank caries.
  142. 142. CONCLUSION • Patient management problems will be solved when the orthodontist understands and employs the psychological principles of human motivation and control. • One golden thread that runs through out the literature of orthodontic psychology is the importance of the doctor-patient relationship. • Once the orthodontist has earned the trust and respect of the patient by establishing a good rapport , the task of achieving a good treatment result is made remarkably easier.
  143. 143. References • William R Proffit, Contemporary Orthodontics, 4th Ed. • Bandura A Social Cognitive theory, Annals of child development, Vol(6), P.No:1-60, 1989 • Ben A. Williams Conditioned Reinforcement. Encyclopedia of Psychology, P No: 495-502, Elsevier Science (USA) Pub • Christopher A. Kearney and Jennifer Vecchio Contingency Management. Encyclopedia of Psychology, P.No: 525-532, Elsevier Science (USA) Pub.
  144. 144. References • Steven Taylor Classic Conditioning. Encyclopedia of Psychology , P.No: 415-429, 1st Edition, Elsevier Science (USA) Pub • Calvin S. Hall, Gardner Lindsey. Freud’s Classical Psychoanalytical theory Theories of Personality, 3rd Edition, P No: 31-75, Johnwiley and Sons Pub. • Nikhil Marwah text book of pediatric dentistry P.NO: 163- 175 ,2nd Edition 2009
  145. 145. References • Roger B. Fillingim and Pramod K. Sinha, An Introduction to Psychologic Factors in Orthodontic Treatment: Theoretical and Methodological Issues (Semin Orthod 2000;6:209-213.) • Judith E.N. Albino, Factors Influencing Adolescent Cooperation in Orthodontic Treatment(Semin Orthod 2000;6:214-223.) • Kolb, D. (1985). Learning style inventory. Boston, MA: McBer and Company
  146. 146. References • H. Asuman Kiyak,Cultural and Psychologic Influences on Treatment Demand (Semin Orthod 2000;6:242-248.) • Hillary L. Broder ,Issues in Decision Making: Should I Have Orthognathic Surgery? (Semin Orthod 2000;6:249-258.) • Semilla M. Rivera, Psychosocial Factors Associated With Orthodontic and Orthognathic Surgical Treatment (Semin Orthod 2000;6:259-269.)
  147. 147. References • Deborah A. Roth, Winnie Eng, Richard G. Heimberg Cognitive Behaviour Therapy. Encyclopedia of Psychology, P No: 451- 458, 1st Edition, Elsevier Science (USA) Pub • Nedra H. Francis, William Allan Kritsonis A Brief Analysis of Abraham Maslow’s Original Writing of Self-Actualizing People: A Study of Psychological Health. National Journal of Publishing and Mentoring Doctoral Student Research Vol 3, No. 1, P.No: 1—7, 2006 • Elizabeth A. Meade, Young patients’ treatment motivation and satisfaction with orthognathic surgery outcomes:The role of ‘‘possible selves’’ Am J Orthod Dentofacial Orthop 2010;137:26-34
  148. 148.