Child psychology/child behavioural management

1. Child Psychology
BY- TUSHAR SAXENA(Final year B.D.S)

2. • CONTENT
• Introduction
• Theories of child psychology
Application
• Classification of child's behavior
• Factors affecting child's behavior
• Behavior management
• Conclusion
• References
.

3. Introduction
 Psychological development is a dynamic process,which begins at birth and
proceeds through a series of sequential stages manifesting in various
characteristic behaviors.
 Therefore a dental clinician needs to understand several dimensions of
child psychology.
 Outcome of an interaction between genetically controlled cell
proliferation and environmental influences.

4. DEFINITIONS
PSYCHOLOGY
 Is the science dealing with human mature function and phenomenon of
his soul in the main.
CHILDPSYCHOLOGY
 It is the science that deals with the dental with the mental power or an
interaction through the conscious and subconscious element in a child.

5. EMOTION An effective state of consciousness in which joy, sorrow, fear, hate
or the likes are expressed.
 BEHAVIOUR It is any change observed in the functioning of the organism.
 BEHAVIOUR MANAGEMENTThe means by which dental health team
effectively and efficiently performs treatment for a child and simultaneously in
stills a positive dental attitude in the child (Wright 1975)

6. Importance of Child Psychology:
 • To better understand the child
 • To know the problem of psychological origin
 • To deliver dental sciences in a meaningful and effective manner
 • To establish effective communication with the child
 • To gain confidence of child and parents
 • To teach child and parent importance of primary and preventive care.
 • To have a better Rx planning and interaction
 • To produce a comfortable environment for dental team to work on the patient

7. THEORIES OF CHILD PSYCHOLOGY
A] Psychodynamic theories
 1.Psychosexual/Psychoanalytic theory
Sigmund Freud (1905)
 2.Cognitive theory
Jean Piaget (1952)
 3.Psychosocial theory
V - Erik Erickson (1963)

8. B] Theories of learning and behavior development
1. Classical conditioning - Pavlov (1927)
2. Operant conditioning - Skinner (1938)
3. Hierarchy of needs - Maslow (1954)
4. Social learning theory - Bandura (1963)
C] Margaret Mahler's theory of development (1933)

9. Psychoanalytic theory
• By Sigmund Freud in 1905
• Personality to originate from biological roots, as
a result of satisfaction of asset of instincts of which
sexual instinct being most important
• Categorized into 5 psychosexual stages
• At each stage sexual energy is invested in a
particular part called erogenous zone

10. 2 models to
describe human
minds
Topographici
model
Psychic
model/triad

11. a] Topographic model
• There are 3 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.
• Subconscious/unconscious - part of personality of which .
individual is unaware, which generally cannot bring into
awareness without help of assistant

12. Mental Iceberg Concept by Sigmund Freud

13. Freud compared human mind to an Iceberg:
 The small part that shows above the surface of the water represents the conscious experience and the
much larger baes below water level represents the unconscious store house of impulses,passions and
inaccessible memories that affects thoughts and behaviors.
 The conscious mind is what you are aware of at any particular moment,your present perceptions
memories thoughts fantasies.
 Working closely with the conscious mind is what Freud called the preconscious mind or available
memory;anything that can be easily made conscious like the memories you are not at the moment
thinking about but can readily bring to mind.
 The largest most complex and hidden is unconsciousness part. According to Freud, unconscious is the
source of our motivation whether they may be simple desires of food or sex, neurotic compulsion or the
motives of an artist or scientist and yet we are often driven to deny or resist becoming conscious of the
motives and they are often available to is only in disguised form.

14. Freud compared human mind to an Iceberg:
♦ So the conclusion is only 10% of the iceberg is
visible or is conscious while other 90% which is
beneath remains unconscious.

15. Psychic model/Psychic triad
ID
SUPER
EGO
EGO

16.  1) ID
• Basic structure of personality, reservoir of instincts
• Based on pleasure principle
• Features of id Present at birth
-Impulse ridden (instinctual)
-Strive for immediate pleasure and gratification
-Selfish and cannot withstand pain
• If retained - aggressive personality

17. 2) EGO
 • Mediator between ID and Super ego
 • Develops out of ID in the 2nd to 6th month of life
 • Based on reality principle
 • It modifies the ID and form the executive part of the personality
 • Concerned with memory and judgment
 • Seat of consciousness
 • It is the actual reality we experience

18. EGO DEFENCE MECHANISMS
 • 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 .
 • DISPLACEMENT: The transfer of hostile and aggressive feelings from a
original source to another, usually a less important one.

19. • IDENTIFICATION: assumption of qualities of some one else to
vent frustration or create fantasy (imitation)
• REACTION FORMATION: Transfer of hostile or more aggressive
impulses into their opposite or more socially desirable form
• RATIONALISATION: A strategy developed to excuse or minimize
the psychological consequences of an event.
• REPRESSION: The process of unconscious forgetting which allows
the suppression, painful experiences into subconscious mind.

20. SUPEREGO:
• Acts as a censor for acceptability of thoughts, feelings and
behavior
• 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.
• Proper parenting is important.

22. Stage 1: Oral stage (0-1 year)
 • Perioral region is the area of pleasure and gratification -
erogenous zone
 • Adequate and regular feeding is very important
 • Dependent stage
 • Satisfaction of this stage helps in the development of trust and
in later years it result in successful achievements of needs
 • If child's needs are not met properly at this stage: excessive
optimism, pessimism, demandingness, envy, jealousy

23. Stage 2: Anal stage (2-3 year)
 • Anal region - the zone of pleasure
 • Ego centric or self centered behavior
 • Maturation of his neuromuscular control
 • Child become more independent and develops personal autonomy.
 • Over emphasis of toilet training causes compulsive, obstinate, and
perfectionist behavior in later life
 • ANAL PERSONALITY: Characterized by disorderliness abstinence,
stubbornness, willfulness, frugality

24. Stage 3: Phallic stage (3-5 year)
 • Child becomes increasingly aware of his or her genitals he can
differentiate the sexes.
 • Character istics:- • Oedipus complex: boys become attached to his mother.
 • Resolution of this crisis for boys is to identify with his father and use him as a role
model.

25. • Electra complex :opposite of Oedipus complex. Girls get
attached to father
• Sense of shame and guilt
• Emergence of jealous and competitive feelings towards peers
and siblings

26. Stage 4: Latency stage (5-12 year)
 • 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 / behavior and decreased development of
skills )
 • Males tend to act as females and females tends to act as Mar males (tom boy)

27. Stage 5: Genital stage (12-18 year)
 • Spurt in sexual activity
 • Hormonal and physiological changes increase the interest in
sexual matters
 • Sense of identity develops
 • Personality matures
 • Helps to separate from dependence of parents
 • Their acceptance of adult role, functions with social ,
expectations and cultural values

28. • 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 behavior

29. PSYCHOSOCIAL THEORY
 Eric Erickson (1963)
 Society responds to child’s basic needs or developmental tasks in a
specific period of life
 Individual passes through 8 developmental stages
 Each stage is characterized by different psychological crisis
 If the individual copes in a maladaptive manner ,he struggles later.

31.  Stage 1:BASIC TRUST v/s BASIC MISTRUST
Infancy: (0-1 year)
Trust vs Mistrust
 ♦ Description: In the first year of life, infants depend 0 others for
food, warmth and affection and therefore mu: be able to blindly trust
the parents (or caregivers) for-providing these.
 ♦ Dental application: This stage identifies with development of
separation anxiety in child. So, f necessary to provide dental
treatment at this early stage, it is preferable to do with the parent
present and preferably with parent holding the child.

32.  Stage 2: AUTONOMY v/s SHAME: Toddler
– 1-2 years
 ♦ Description: Toddlers learn to walk, talk, use toilets and do things for
themselves. Their self-control and self-confidence begins to develop at
this stage.
 ♦ Dental application: Child is moving away from mother, but still we retreat to
her in threatening situations. So parent's presence is essential in dental
clinic. At this stage as the child takes pleasure in doing tasks by himself/
herself; dentist must obtain co-operation from him by making him
believe that the treatment is his choice not of the parent/dentist. STAGE
3: Early Childhood—Age 2 to 6 Years

33.  Stage 3:INITIATIVE v/s GUILT: Early
Childhood-2-6 years
 ♦ Description: Children have newfound power at this stage as
they have developed motor skills and become more engaged in
social interaction with people around them. They now must
learn to achieve a balance between eagerness for more
adventure and more responsibility and learning to control
impulses and childish fantasies.
 ♦ Dental application: Child may be encouraged to view this visit
as new adventure and is encouraged to genuine success in it. If
there is failure in this visit, this causes sense of guilt in child.
Child should be inherently teachable at this stage and so can be
taught about various things in dental set up.

34.  Stage 4: Elementary and Middle School
Years—Age 6 to 12 years
 Industry vs Inferiority
 ♦ Description: Here child learn basic cultural skills such as school skills. Child who,
because of his successive and successful resolutions of earlier psychosocial crisis is
trusting, autonomous and •full of initiative will learn easily enough to be
industrious. However, the mistrusting child will doubt the future. Shame and guilt
filled child experience defeat and inferiority.
 Dental application: Child drive for sense of industry and accomplishment,
cooperation with treatment can be obtained. This needs to be reinforced positively.
Cooperation during this stage depends on whether he/she understand what is
needed to please dentists/ parents, whether the peer group is supportive and
whether the desired behavior is reinforced by the dentist.

35. Stage 5: Adolescence –Age 12-18 years
 Description: This time when we ask the question ‘who am
I’?. To successfully answer this question Erickson suggest
the adolescent must integrate the healthy resolutions of all
early conflicts are ready for the Identity crisis, which is
considered by Erickson as the single most significant
conflict a person must face.
 Dental Application: Behavior management of adolescents
can be challenging, Any orthodontic treatment can be
carried out if child wants it and not parents at this stage,
parental authority has been rejected. Approval of peer
group is very important.

36. Stage:6 Young Adulthood—Age 19-40
 Intimacy versus Isolation
 Description: In this stage, the most important events are love relationships. No matter
how successful you are with your work, said Erickson you are not developmentally
complete until you are capable of intimacy. An individual who has not developed a
sense of identity usually will fear a committed relationship and may retreat into
isolation.
 Dental application: During this stage, external appearances should be very important
as this helps in gaining of intimate relation. These young adult seek orthodontic
treatment to correct their dental appearances and this is characterized as internal
motivation. Alteration of appearances can also interfere with previously established
relations, so treatment options should be explained fully and are discussed with young
adults.

38. Stage 7:Middle Adulthood—Age 40-65 Years
 Generativity versus Stagnation
Description: By generativity Erickson refers to the
adult's ability to look outside oneself and care for
others through parenting.

39. Stage 8:Late Adulthood—Age 65 Years to Death
Integrity versus Despair
Description: Old age is a time for reflecting upon one's °want
life and seeing it filled with pleasure and satisfaction
disappointments and failure.

41. MERITS: -Easy to apply at any stage of the classification –
Simple and comprehensive to understand
DEMERIT : Based on extreme ends of personality

42.  Cognitive Theory
 • By Jean Piaget in 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

43. • Two types of cognitive structure
• Simple mental structure present at birth
• Internal representation of some specific action
or behavior
 • Develop later in cognitive development
 • More complex
 • Represent internal structures of a high order that have
the distinctive features of being reversible
Schemes
Operations

44. ADAPTATION OF COGNITIVE STRUCTURE
 • By two process
 • Assimilation: Refers to incorporation of new objects, thoughts, and behavior 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.

47. Sensorimotor stage (birth to 2yrs)
 • 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.

48. • As maturation progresses the simple reflexes begin to be coordinated.
• E.g. arm is moved, eyes keep on watching it
• By 10th month, variety of elementary schemes develop.
• Permanent relating of object develops in course of coordinating actions
with repeated contacts with environment

49. Dental application:
 • Child begins to interact with the environment and can be given toys
while sitting on a dental chair in his hand

50. B] Preoperational stage (2 to 6yrs)
 • Primitive strategies changes as 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
 • Concept of egocentrism
 • Unaware of others perspective

51. egocentrism

52. Immediate sensory impressinos

53. Dental Applications:
 • Constructivism
 • Cognitive equilibrium
 • Animism
 Some-times they just need a little help to stop a thumb clung it

54. Concrete operation stage (6 to 12yrs)
 • 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

55. Conservation Concepts
Changing the appearance or arrangement of objects does not
change their key properties

56. Dental application:
 • Concrete instructions like this is a retainer, brush like this
 • Abstract instructions like wear the retainer every night and keep clean
 • Centering - allowed to hold the mirror to see what is being done on his teeth
 • Egocentrism - achieved level of understanding and gets involved in the treatment

57. bl Formal operation stage (11 to 15yrs)
 • Development of reasoning capacity
 • Child able to think more abstractly
 • Can imagine possibilities inherent in a problem
 • Uses inductive (or) deductive logic to make decisions to solve problems
 • Thinks of ideas and has developed a vast imagination

58. Dental application:
• Peer influence and abstract thinking increases
• Play important role in orthodontic appliances and braces
• Imaginary audience (by Elkind)
 • Personal fable

60. 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 child rather than cognitive
ability
Piaget was better at describing processes than explaining how they
operate.

61. CLASSICAL CONDITIONING
• By Ivan Pavlov in 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).

62.  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.

63. Classical conditioning

64. Classical conditioning

65. OPERANT CONDITIONING
• Skinner in 1938
• The consequence of behavior itself acts as a stimulus and affect
future behavior
• Operant: behavior that operates or controls the environment
Stek.

66. 1. Positive reinforcement
• Occurs if a pleasant consequence follows the response e.g., a child
rewarded for good behavior 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
behavior.

67. 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 behavior.
4. Punishment • Involves introduction of an aversive stimulus into
a situation to decrease the undesirable behavior, e.g., use of
parental rake in correction of tongue thrusting habit.

68. + positive
-Negative

69. 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

70. 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 I do the same at a time when he
is involved in an enjoyable activity.

71. Classification of Child’s behavior

72. Frankel behavior rating scale:
FRANKEL(1962)
Definitely
negative (--)
Positive (4-)
Definitely
positive (++)
Negative (-)

74. Factors affecting child's behavior
effect of dental office environment
 Dentist's attire
Presence/absence of parents in the operatory
Presence of older sibling
Effect dentist attitude and activity

75. Out of control of dentist:

76. Under control of parents:
Home environment
 Family development and peer influence
Maternal behavior

77. Behavior Management:

78. • Behavior management (Wright 1975)
 Means by which the dental health team effectively and efficiently
performs dental treatment and thereby instills a positive dental attitude
• Behavior shaping
 Procedure which slowly develops behavior by reinforcing a successive
approximation of the desired until the desired, behavior comes into
being

79. Pharmacological
 Non-
pharmacological
communication
Behavior shaping
Behavior
Management
Conscious
sedation
Premedication
General
anesthesia
Classification of
behavior management

80. Communicative Management
• Used in both cooperative and uncooperative child
(Chambers in 1976)
• Basis for establishing a relationship with the child
• The communication should always be established from the
first entry i.e. to the reception area

81. Types of communication:
 1. Verbal
 2. Nonverbal
 • Body language
 • Smiling
 • Eye contact
 • Expression of feeling
 • Showing concern
 • By touching the child
 • Giving him a pat
 • Giving a hug
 3. Using both

83. Behavior shaping
1] Desensitization
• Joseph Wolpe (1975)
• It is accompanied by teaching the child a competing
response such as relaxing and then introducing a
threatening stimuli

84. Tell Do Show (TbS)
• Addleston in 1959
• Continuously and in grades the procedure should be moved from
the least fear promoting object to more fearful ones.
• Indication for TBS: • 1st visit.
 • Subsequent visits when introducing new procedure
 • Fearful child.
 • Apprehensive child because of information received by peers or parents .

85. 2] Modeling
• Bandura in 1969
• Social learning principle
• Modelling can be done by
• Live models - siblings, parents of child etc.,
• Filmed models
• Posters
 • Audio - visual aids.

86. 3] Contingency management
 • Method of modifying the behavior by presentation or withdrawal of
reinforcers
 • A +ve reinforcers: Henry W Fields in 1984. In this the contingent
presentation increases the frequency of behavior.
 • B -ve rein forcers: Stokes and Kennedy in 1980. In this, the contingent
withdrawal increases the frequency of behavior this is generally a
termination of an aversive stimulus. E.g. withdrawal of the mother.

87. Behavior Management:

88. 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.

89. references
Book of PEDODONTICS SHOBHA TONDON