psychological management of orthodontic patient

CHILD PSYCHOLOGY
-ANUSHA G H
-PG STUDENT
-VSDCH
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CONTENTS
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•INTRODUCTION
•CLASSIFICATION
•PSYCHOSEXUALTHEORY
•PSYCHOSOCIALTHEORY
•COGNITIVETHEORY
•HIERARCHY OF NEEDS
•SOCIAL LEARNINGTHEORY
•CLASSICALCONDITIONING THEORY
•OPERANT CONDITIONING THEORY
•IMPLICTION OF PSYCHOLOGY IN ORTHODONTICS
•CONCLUSION
•REFERENCE

INTRODUCTION
•Psychological development is a dynamic process, which
begins at birth and proceeds in an ascending order through a
series of sequential stages manifesting in various
characteristic behaviors.
•These stages are governed by genetic, familial, cultural and
interpersonal factors.
•Therefore a dental clinician needs to understand several
dimensions of child psychological development in order to
relate effectively and to guide the patient.
•The clinician should know what emotional and social
behavior to expect from children in different age groups, and
should also be able to communicate on a level consistent with
the patient’s view.
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PSYCHOLOGY :
It is the science of behavior and mind, including conscious and
unconscious phenomenon as well as feeling and thought.
CHILD PSYCHOLOGY: It is the science or study of child’s mind
and how it functions. It is also the science that deals with the
mental power or an interaction between the conscious and sub-
conscious elements in a child.
EMOTION :
Emotion is any conscious experience, characterized by intense
mental activity and a certain degree of pleasure or displeasure.
BEHAVIOR: It is any change observed in the functioning of the
organism.
Psychology: six perspectives, Fernald, 2008
Panksepp, Jaak (2005). Affective neuroscience : the foundations of human and animal
emotions 4113

CLASSIFICATION
Psychodynamic Theories:
•Psychosexual Theory –Sigmund Freud
•Psychosocial Theory-Eric Erickson
•Cognitive Theory- Jean Piaget
Behavioral Learning Theories:
•Hierarchy of needs – Abraham Maslow
•Social Learning Theory-Albert Bandura
•Classical Conditioning Theory-Ivan Pavlov
•Operant Conditioning Theory-Skinner
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PSYCHOSEXUAL OR PSYCHOANALYTICALTHEORY
• Sigmund Freud was originator of
psychoanalytical approach in the year
1905.
• Freud’s interest in development arose
from his desire to explain the disorders
of personality in adults.
• Freud believed that personality
develops through a series of childhood
stages during which the pleasure
seeking energies become focused on
certain erogenous areas. These
psychosexual energies, or libido, were
described as the driving force behind
behavior
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According to Freud’s psychoanalytic theory of personality,
personality is composed of three elements.
They are known as the id, the ego, and the superego which
work together to create complex human behaviors.
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The ID
•The id is the only component of personality that is present from birth
•This aspect of personality is entirely unconscious and includes
instinctive and primitive behaviors.
•Id is the source of all psychic energy, making it the primary component
of personality.
•The id is driven by the pleasure
principle, which strives for
immediate gratification of all
desires, and needs.
•If these needs are not satisfied
immediately, the result is a state
of anxiety or tension.
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•Behavior ruled entirely by the pleasure principle can be both
disruptive and socially unacceptable.
•The id tries to resolve the tension created by the pleasure
principle through the primary process, which involves forming a
mental image of the desired object as a way of satisfying the
need.
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The EGO
•The ego is the component of personality that is responsible for dealing
with reality.
•Ego develops from the id and
ensures that the impulses of the
id can be expressed in a manner
acceptable in the real world.
The ego functions in the conscious,
preconscious, and unconscious
mind.
•The ego operates based on the reality
principle, which strives to satisfy the id’s desires in realistic and
socially appropriate ways.
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•In many cases, the id’s impulses can be satisfied through a
process of delayed gratification—the ego will eventually allow the
behavior, but only in the appropriate time and place.
•The ego also discharges tension created by unmet impulses
through the secondary process, in which the ego tries to find an
object in the real world that matches the mental image created by
the id’s primary process.
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The SUPEREGO
•Is the aspect of personality that holds all of our internalized moral
standards and ideals that we acquire from both parents and society-our
sense of right and wrong.
• The superego provides guidelines for making judgments.
•The superego begins to emerge at around age five.
•Has two parts:
1)The ego ideal -includes the rules and standards for
good behaviors. These behaviors include those which
are approved of by parental and other authority figures.
Obeying these rules leads to feelings of pride, value, and
accomplishment.
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• 2)The conscience- includes information about things that
are viewed as bad by parents and society. These behaviors
often lead to bad consequences, or feelings of guilt.
• The superego acts to perfect and civilize our behavior. It
works to suppress all unacceptable urges of the id and
struggles to make the ego act upon idealistic standards
rather that upon realistic principles.
• The superego is present in the conscious, preconscious,
and unconscious mind.
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STAGES
There are 5 stages in Psycho Analytical theory
• Oral stage (0 -1.5yrs)
•Anal stage ( 1.5 – 3 yrs)
•Phallic stage ( 3-5 yrs)
•Latency Period ( 5 – puberty)
•Genital stage ( Puberty onwards)
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The Oral Stage (0 to 1.5 yr )
• The infant’s primary source of interaction occurs through the
mouth, so the rooting and suckling
reflex is especially important.
• The mouth is vital for eating, and the
infant derives pleasure from oral
stimulation through gratifying
activities such as tasting and suckling.
• Because the infant is entirely
dependent upon caretakers, the infant
also develops a sense of trust and
comfort through this oral stimulation.
• The primary conflict at this stage is the weaning process the child
must become less dependent upon caretakers.
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•If a person has difficulties in the tasks associated with the
stage - weaning – he will tend to retain certain infantile habits.
This is called fixation.
• Fixation gives problem at each stage and a long term effect in
terms of our personality
•If a child is frustrated in his need to suckle, then he may
develop an oral-passive character.
•An oral-passive personality tends to be dependent on others.
They often retain an interest in "oral gratifications" such as
eating, drinking, and smoking. It is as if they were seeking the
pleasures they missed in infancy.
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•When child is between five and eight months of age , the process
of teething starts.
• One satisfying thing to do when teething is to bite on something.
If this causes a great deal of upset to the mother and precipitates an
early weaning, child may develop an oral-aggressive personality.
•These people retain a life-long desire to bite on things, such as
pencils, gum etc.
•They have a tendency to be verbally aggressive, argumentative &
sarcastic
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The Anal Stage (2 to 3 yr)
•The primary focus of the libido is on
controlling bladder and bowel movements.
•The major conflict at this stage is toilet
training, the child has to learn to control his or
her bodily needs.
•Developing this control leads to a sense
of accomplishment and independence.
•Success at this stage is dependent upon
the parents approach to toilet training.
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•If parents take an approach that is too lenient, an anal-expulsive
personality can develop in which the individual has a messy,
wasteful, or destructive personality.
•If parents are too strict or begin toilet training too early, an anal
retentive personality develops in which the individual is stringent,
orderly, rigid, and obsessive.
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The Phallic Stage (3 to 7 yr)
•The primary focus of the libido is on the genitals.
•Children discover the differences between males and females.
•Boys begin to view their fathers as a rival for the mother’s affections.
•The Oedipus complex describes these feelings of wanting to possess the
mother and the desire to replace the father.
•However, the child also fears that he will be punished by the father for
these feelings, a fear Freud termed castration anxiety.
•The term Electra complex has been used to described a similar set of
feelings experienced by young girls.
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The Latent Period (8 to 11 yr)
•During the latent period, the libido interests are suppressed. The
development of the ego and superego contribute to this period of calm.
•The stage begins around the time that children enter into school and
become more concerned with peer
relationships, hobbies, and other
interests.
•The latent period is a time of
exploration in which the sexual
energy is still present, but it is
directed into other areas such as
intellectual pursuits and social
interactions.
•This stage is important in the development of social and communication
skills and self-confidence. 21113

The Genital Stage (12 yrs to adult)
•During the final stage of psychosexual development, the individual
develops a strong sexual interest in the opposite sex.
•Where in earlier stages
the focus was solely on
individual needs, interest
in the welfare of others
grow during this stage.
• If the other stages have
been completed
successfully, the individual should now be well balanced, warm, and
caring.
•The goal of this stage is to establish a balance between the various
life areas.
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•Erikson is a Freudian ego-
psychologist.
•He accepts Freud's ideas as basically
correct, including the more debatable
ideas such as the Oedipal complex,
and the ideas about the ego.
•However, Erikson is much more
society and culture-oriented than
Freud.
•Eric Erickson divided this theory
into eight stages
PSYCHO-SOCIALTHEORY – ERIC ERIKSON (1963)
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Erik Erikson’sTheory of Psychosocial Development, MAY 2019
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The first stage – trust vs mistrust, (0 to 18 mo)
•The task is to develop trust without completely eliminating the capacity
for mistrust.
•If mother and father can give the newborn a
degree of familiarity, consistency, then the child
will develop the feeling that the world is a safe
place to be and learns to trust his or her own
body and the biological urges that go with it.
•If the parents are unreliable and inadequate,
if they reject the infant , then the infant will
develop mistrust. He or she will be
apprehensive and suspicious about people.
•Parents who are overly protective of the child, will lead that child into
the maladaptive tendency of sensory maladjustment.
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•Worse, is the child whose balance is tipped way over on the
mistrust side, they develop the malignant tendency of
withdrawal, characterized by depression and possibly psychosis.
•If the proper balance is achieved, the child will develop the virtue
hope, the strong belief that, even when things are not going well,
they will work out well in the end.
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Stage two- Autonomy vs shame (18 months to 3 yrs)
•The task is to achieve a degree of autonomy while minimizing shame
and doubt.
•If mom and dad , permits the child, to explore
and manipulate his or her environment, the
child will develop a sense of autonomy or
independence.
•If the parents come down hard on any attempt
to explore and be independent, the child will
soon give up with the assumption that cannot
and should not act on their own.
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•A little "shame and doubt" is not only inevitable, but beneficial.
•Without it, child will develop the maladaptive tendency called
impulsiveness, a shameless feeling that leads him to do things
without proper consideration of his abilities.
•Too much shame and doubt, will lead to the malignancy of
compulsiveness.
•The compulsive person feels that everything must be done
perfectly.
•If child get the proper, positive balance, he will develop the virtue
of willpower or determination.
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•A key toward obtaining cooperation with treatment from a child at
this stage is to have the child think that whatever the dentist wants was
his or her own choice, not something required by another person.
•For a 2-year-old seeking autonomy, he will open his mouth if he
wants to, but almost psychologically unacceptable to do it if someone
tells him to.
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Stage three: initiative vs guilt (3 -5 yrs)
•The task of this stage is to learn initiative without too much guilt.
•Initiative means a positive response
to the world's challenges, taking on
responsibilities, learning new skills,
feeling purposeful.
•Parents can encourage initiative by
encouraging children to try out their
ideas.
•Erikson includes the Oedipal
experience in this stage.
•Oedipal crisis involves a child's feeling in relinquishing his or her
closeness to the opposite sex parent. A parent has the responsibility,
socially, to encourage the child to “grow up”. But if this process is done
too harshly ,the child learns to feel guilty about his or her feelings. 30113

•Too much initiative and too little guilt means a maladaptive
tendency of ruthlessness. It's just that they don't care who they
step on to achieve their goals.
• Malignancy of too much guilt, which Erikson calls inhibition.
•The inhibited person will not try things because "nothing
ventured, nothing lost" and, nothing to feel guilty about.
•A good balance leads to the psychosocial strength of courage.
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• For most children ,first dental visit comes in this age of initiative.
Going to dentist comes as a challenge, in which a child can
experience success .Success in coping with this anxiety helps to
develop greater independence and produce a sense of
accomplishment.
• Poorly managed dental visit can also contribute toward the guilt
that accompanies failure. A child at this stage will be intensely
curious about the dentists office and eager to learn about the things
found there. An exploratory visit with the mother present and with
little treatment accomplished usually is important in getting the
dental experience to a good start.
• After the initial experience, a child at this stage can usually tolerate
being separated from the mother for treatment and is likely to
behave better in this arrangement, so that independence rather than
dependence is reinforced.
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Stage four- industry vs inferiority (5 to 13 years)
•The task is to develop a capacity for industry while avoiding an
excessive sense of inferiority.
•The parents are joined by teachers
and peers. They all contribute.
•Parents must encourage, teachers
must care, peers must accept .
•They must learn the feeling
of success, whether it is in school
or on the playground, academic or social.
•If the child is allowed too little success, because of harsh teachers or
rejecting peers, then he or she will develop a sense of inferiority .
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•Too much industry leads to the maladaptive tendency called
narrow virtuosity. E.g. : child actors.
•Much more common is the malignancy called inertia.
•This includes all of us who suffer from the "inferiority
complexes" .
•If at first we don't succeed, we don't try again! We become
inert.
•The right balance of industry and inferiority will keep us
sensibly humble, then we have the virtue called competency.
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Stage five –identity vs role ( 13 to 21 years)
Ego identity and avoid role confusion.
Ego identity means knowing who you are and how you fit in to the rest
of society.
Role confusion, meaning an uncertainty about one's place in society and
the world. An adolescent asks a straight-forward question of identity:
"Who am I?"
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•Too much "ego identity," where a person is so involved in a
particular role in a particular society that there is no room left for
tolerance. This maladaptive tendency is called fanaticism.
•The lack of identity is referred as repudiation, they repudiate
their need for an identity. Some adolescents allow themselves to
"fuse" with special kind of group that is particularly eager to
provide the details of their identity.
•If one successfully negotiates this stage, he will have the virtue
of fidelity. Fidelity means loyalty, the ability to live by societies
standards despite their imperfections and inconsistencies ,a
person has found a place in that community, a place that will
allow him to contribute.
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•Most orthodontic treatment is carried out during the adolescent
years, and behavioral management of adolescents can be
extremely challenging.
•Since parental authority is being rejected, a poor psychological
situation is created by orthodontic treatment if it is being carried
out primarily because the parents want it, not the child.
•At this stage, orthodontic treatment should be instituted only if
the patient wants it, not just to please the parents.
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Stage six: intimacy vs isolation(21to about 39yr)
•The task is to achieve intimacy, as opposed to remaining in isolation.
•Intimacy is the ability to be close to others, as a lover, a friend, and as a
participant in society .A person has clear sense of who he is , he no
longer need to fear of "losing" himself, as many adolescents do.
•The maladaptive form called as
promiscuity, referring particularly to
the tendency to become intimate
too freely, too easily, and without
any depth.
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•The malignancy is exclusion ,refers to the tendency to isolate oneself
from love, friendship, and community, and to develop a certain
hatefulness in compensation for one's loneliness.
•If one successfully negotiate this stage, he will carry with him the
virtue called love. Love, means being able to put aside differences and
antagonisms through "mutuality of devotion."
•A growing number of young adults are seeking orthodontic care. Often
these individuals are seeking to correct a dental appearance they perceive
as flawed.
•They may feel that a change in their appearance will facilitate
attainment of intimate relationships. On the other hand, a "new look"
resulting from orthodontic treatment may interfere with previously
established relationships.
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Stage seven: generativity vs stagnation (40-65 yr).
•The task here is to cultivate the proper balance of generativity and
stagnation.
•Generativity is an extension of love into the future. It is a concern for
the next generation.
•Stagnation, on the other hand, is
self absorption, caring for no one.
The stagnant person ceases to be a
productive member of society.
•The maladaptive tendency is termed as
overextension .
Some people try to be so generative
that they no longer allow time for
themselves, for rest and relaxation.
•The malignant tendency is rejectivity. Too little generativity and too
much stagnation and you are no longer participating in or contributing to
society. 40113

Stage eight: integrity vs despire (65 and older)
•The task is to develop integrity with a minimal amount of despair.
•Despair- some older people become preoccupied with their past. They
think, that's where the things were better. Become preoccupied with
their failures, bad decisions and regret them.
•Ego integrity means coming to terms with your life, and thereby
coming to terms with the end of life.
•If they are able to look back and accept the course of events, the
choices made, the life as they lived it, as being necessary, then they
don`t fear death.
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•The maladaptive tendency is called presumption. This is what
happens when a person "presumes" ego integrity without actually
facing the difficulties of old age.
• The malignant tendency is called disdain, which means a contempt
of life.
•Someone who approaches death without fear has the strength,
Erikson calls wisdom. He calls it a gift to children, because "healthy
children will not fear life if their elders have integrity enough not to
fear death."
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•Jean Piaget began his career as a
mycologist.
•But his interest in science soon
overtook his interest in snails and
clams.
•As he delved deeper into the
thought-processes , he became
interested in the nature of thought
itself, especially in the development
of thinking.
•He called it genetic epistemology,
meaning the study of the
development of knowledge.
COGNITIVETHEORY – JEAN PIAGET (1952)
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Stages
• The sensorimotor stage ( from birth to two years)
• Preoperational stage (two to about seven years)
• Concrete operations stage ( 7 to11 yrs)
• Formal operations stage . (12 yrs to adult)
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The sensorimotor stage ( from birth to two years)
•As the name implies, the infant uses senses and motor abilities to
understand the world, beginning with
reflexes and ending with complex
combinations of sensorimotor skills.
• Between one and four months, the child
works on primary circular reactions –
just an action of his own which serves as a
stimulus to which it responds with the same
action, and around and around.
•Between four and 12 months, the infant
turns to secondary circular reactions,
which involve an act that extends
out to the environment.
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•Between 12 months and 24 months, the child works on tertiary
circular reactions. They consist of the same making interesting
things last, except with constant variation.
•This kind of active
experimentation is best seen during
feeding time, when discovering new
and interesting ways of throwing
spoon, dish, and food.
•Around one and a half years, the
child is clearly developing mental
representation, that is, the ability to
hold an image in their mind for a
period beyond the immediate
experience.
•They can use mental combinations to solve simple problems, such
as putting down a toy in order to open a door.
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Preoperational stage (two to about seven years).
•The child is quite egocentric during this stage, that is, he sees things
pretty much from own point of view.
•Piaget did a study to investigate this
phenomenon called the mountains
study.
•He would put children in front of a
simple plaster mountain range and
seat himself to the side, then ask
them to pick from four pictures the
view that he, Piaget, would see.
•Younger children would pick the picture of the view they themselves
saw; older kids picked correctly.
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•The most famous example of the preoperational child's centrism is what
Piaget refers to as their inability to conserve liquid volume.
•If we give a three year old some chocolate
milk in a tall skinny glass, and we give
ourself a whole lot more in a short fat glass,
he will tend to focus on only one of the
dimensions of the glass.
•Since the milk in the tall skinny glass goes
up much higher, he is likely to assume that
there is more milk in that one than in the
short fat glass, even though there is far more
in the latter.
•It is the development of the child's ability to decenter which marks him
as having moved to the next stage.
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•At this stage, capabilities for logical reasoning are limited, and the
child's thought processes are dominated by the immediate sensory
impressions. So the dental staff should use immediate sensations
rather than abstract reasoning in discussing concepts like prevention
of dental problems with a child at this stage.
•Excellent oral hygiene is very important
when an orthodontic appliance is
present.
•A preoperational child will have
trouble understanding a chain of
reasoning like the following:
"Brushing and flossing remove food
particles, which in turn prevents
bacteria from forming acids, which
cause tooth decay."
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•He is much more likely to understand: "Brushing makes your teeth
feel clean and smooth” and, "Toothpaste makes your mouth taste
good” because these statements rely on things the child can taste or
feel immediately.
•Another characteristic of thought process
in this stage is Animism-investing
inanimate objects with life.
•For example while talking to a 4-year-
old about how desirable it would be to
stop thumb sucking .
•The orthodontist might tell the child to
accept the idea that "Mr. Thumb" is the
problem and the child should
form a partnership with the orthodonist to control Mr. Thumb who
wishes to get into the child's mouth.
•Animism, in other words, can be applied even to parts of the child's
own body, which seem to take on a life of their own in this view 50113

•On the other hand, it would not be useful to point out to the
child how proud his father would be if he stopped sucking
his thumb, since the child would think his father's attitude is
not the same as the child's (egocentrism).
•Since the child's view of time is centered around the
present, and he or she is dominated by how things look, feel,
taste, and sound now, there is no point in talking to the 4-
year-old about how much better his teeth will look in the
future if he stops sucking his thumb.
•Telling him that the teeth will feel better now or talking
about how bad his thumb tastes, however, may make an
impact, since he can relate to that.
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Concrete operations stage ( 7 to 11 yrs).
•The word operations refers to logical principles we use when solving
problems. In this stage, the child not only uses symbols
representationally, but can manipulate
those symbols logically.
•But, at this point, they still perform
these operations within the context of
concrete situations.
• By six or seven, most children
develop the ability to conserve number, length, and liquid volume.
•Conservation refers to the idea that a quantity remains the same despite
changes in appearance. And he will know that you have to look at more
than just the height of the milk in the glass.
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•If we take a ball of clay and roll it into a long thin rod, or even
split it into ten little pieces, the child knows that there is still
the same amount of clay. And he will know that, if we rolled it
all back into a single ball, it would look quite the same as it did
-- a feature known as reversibility.
•By nine or ten, the last of the
conservation tests is mastered-
conservation of area.
•In addition, a child learns
classification and seriation during this
stage. Now the child begins to get the idea that one set can
include another.
•Seriation is putting things in order. The younger child may
start putting things in order by, say size, but will quickly lose
track. Now the child has no problem with such a task. Since
arithmetic is essentially nothing more than classification and
seriation, the child is now ready for some formal education! 53113

•By this stage, the ability to see another point of view
develops, while animism declines .Children in this period
are much more like adults in the way they view the world
but they are still cognitively different from adults.
•Presenting ideas as abstract concepts rather than
illustrating them with concrete objects can be a major
barrier to communication.
•Instructions must be illustrated with concrete objects
"Now wear your retainer every night and keep it clean," is
too abstract. More concrete direction would be: "This is
your retainer. Put it in your mouth like this, and take it out
like that. Put it in every evening after dinner before you go
to bed, and take out before breakfast every morning. Brush
it like this with toothbrush to keep it clean”.
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Formal operations stage . (12 yrs to adult)
•Around 12 yrs of age, child enter the formal operations stage. Here he
become increasingly competent at adult-style thinking. This involves
using logical operations, and using them in the
abstract, rather than the concrete. We call this as
hypothetical thinking.
•Child is capable of understanding concepts like
health disease ,preventive treatment etc.
•At this stage child should be treated like an
adult.
•A new expression of egocentrism develops ,
they presume that they and others are thinking
about the same thing. Because young adolescents are experiencing
tremendous biologic changes in growth and sexual development, they
are preoccupied with these events. 55113

•When an adolescent considers what others are thinking about, he
assumes that others are thinking about the same thing he is thinking
about, namely himself. Adolescents assume that others are as concerned
with their bodies, actions, and
feelings as they themselves are.
•They feel as though they are
constantly "on stage," being
observed and criticized by those
around them. This phenomenon
has been called as the
"imaginary audience".
•The imaginary audience is a powerful influence on young adolescents,
making them quite self conscious and particularly susceptible to peer
influence. They are very worried about what peers will think about their
appearance and actions, not realizing that others are too busy with
themselves to be paying attention to much other than themselves.
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•The reaction of the imaginary audience to braces on the teeth, is an
important consideration to a teenage patient.
•As orthodontic treatment has become more common ,adolescents have
less concern about being singled out because they have braces on their
teeth, but they are very susceptible to suggestions from their peers about
how the braces should look.
•This has led to pleas for tooth-colored plastic or
ceramic brackets to make them less visible.
•Brightly colored ligatures and elastics have also
become popular among adolescent ,they feel that
everybody is wearing them so they should also.
•The notion that "others really care about my
appearance and feelings as much as I do" leads adolescents to think they
are quite unique, special individuals.
•Because of this thought process a second phenomenon emerges which is
called as “personal fable”.
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•Both the imaginary audience and the personal fable are likely
to have significant influence on orthodontic treatment. The
imaginary audience, depending on what the adolescent
believes, may influence him to accept or reject treatment, and
to wear or not to wear appliances.
•The personal fable may make a patient ignore threats to
health, such as decalcification of teeth from poor oral hygiene
during orthodontic therapy. The thought is "Others may have
to worry about that, but I don't.“
•The challenge for the orthodontist is not to try to impose
change on reality as perceived by adolescents, but rather to
help them to see more clearly the actual reality that surrounds
them.
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•Maslow used the terms "physiological",
"safety", "belongingness“, "love", "esteem",
"self-actualization“ to describe the pattern
that human motivations generally move
through.
•Maslow's theory was fully expressed in his
1954 book Motivation and Personality. The
hierarchy remains a very popular
framework in sociology research,
management training and secondary and
higher psychology instruction.
HIERARCHY OF NEEDS – ABRAHAM MASLOW
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• The most fundamental and basic four layers of the pyramid contain
what Maslow called "deficiency needs" or "d-needs": esteem,
friendship and love, security, and physical needs. If these
"deficiency needs" are not met – with the exception of the most
fundamental (physiological) need – there may not be a physical
indication, but the individual will feel anxious and tense.
• Maslow's theory suggests that the most basic level of needs must be
met before the individual will strongly desire the secondary or
higher level needs. Maslow also coined the term "metamotivation"
to describe the motivation of people who go beyond the scope of the
basic needs and strive for constant betterment.
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Physiological needs
•Physiological needs are the physical requirements for human survival. If
these requirements are not met, the human body cannot function properly
and will ultimately fail. Physiological needs are thought to be the most
important; they should be met first.
•Air, water, and food are metabolic requirements for survival in all
animals, including humans. Clothing and shelter provide necessary
protection.
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Safety needs
•With their physical needs relatively satisfied, the individual's safety
needs take precedence and dominate behavior.
•In the absence of economic safety – due to economic crisis and lack of
work opportunities – these safety needs manifest themselves in ways
such as a preference for job security, grievance procedures for protecting
the individual from unilateral authority, savings accounts, insurance
policies, reasonable disability accommodations, etc. This level is more
likely to be found in children because they generally have a greater need
to feel safe.
•Safety and Security needs include:
1. Personal security
2. Financial security
3. Health and well-being
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Love and belonging
•After physiological and safety needs are fulfilled, the third level of
human needs is interpersonal and involves feelings of belongingness.
Deficiencies within this level of Maslow's hierarchy – due to
hospitalism, neglect, shunning, etc. – can impact the individual's
ability to form and maintain emotionally significant relationships in
general, such as:
• Friendship
• Intimacy
• Family
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Self Esteem
•All humans have a need to feel respected; this includes the need to have
self-esteem and self-respect. Esteem presents the typical human desire to
be accepted and valued by others. People often engage in a profession or
hobby to gain recognition. These activities give the person a sense of
contribution or value.
•Low self-esteem or an inferiority complex may result from imbalances
during this level in the hierarchy. People with low self-esteem often need
respect from others; they may feel the need to seek fame or glory.
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Self-actualization
•This level of need refers to what a person's full potential is and the
realization of that potential.
•Maslow describes this level as the desire to
accomplish everything that one can, to become
the most that one can be.
•Individuals may perceive or focus on this need
very specifically. For example, one individual
may have the strong desire to become an ideal
parent. In another, the desire may be expressed
athletically. For others, it may be expressed in paintings, pictures, or
inventions.
•As previously mentioned, Maslow believed that to understand this level
of need, the person must not only achieve the previous needs, but master
them. 66113

•Albert Bandura was born on
December 4, 1925, in the small
town of Mundare in northern
Alberta, Canada.
•He received his bachelors degree
in Psychology from the University
of British Columbia in
1949. He went on to the University
of Iowa, where he received his
Ph.D. in 1952.
•It was there that he came under the
influence of the behaviorist
tradition and learning theory.
SOCIAL LEARNINGTHEORY- ALBERT BANDURA
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According to Bandura the steps involved in the modeling are:
1. Attention. If we are going to learn anything, we have to pay
attention. Likewise, anything that puts a stop on our attention is going to
decrease learning, including observational
learning.
•Main thing that influence attention
involves characteristics of the model.
• If the model is colorful and dramatic,
attractive, or prestigious, or appears to be
particularly competent, we will pay more
attention.
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2. Retention. Second, we must be able to retain what we have paid
attention to. This is where imagination and language come in. We
store what we have seen the model doing in the form of mental images
or verbal descriptions. When so stored, we can later bring up the
image or description, so that we can reproduce it with our own
behavior.
3. Reproduction. we have to translate the images or descriptions
into actual behavior. So we should have the ability to reproduce the
behavior in the first place.
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4. Motivation. And yet, with all this, we are still not going to do
anything unless we are not motivated to imitate, i.e. until we have
some reason for doing it.
Bandura mentioned following motives:
a. past reinforcement.
b. promised reinforcements - incentives.
The negative motivations are which, giving us reasons not to imitate :
a. past punishment.
b. promised punishment (threats).
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•Children are capable of performing almost any behavior that they
observe closely and that is not too complex for them to perform at their
level of physical development.
•Most of the behavior which he acquires may not be expressed
immediately or ever.
•Whether a child will actually
perform an acquired
behavior depends on several
factors.
•Important among these are:
A) Role model.
•If the model is liked or respected, the child is more likely to imitate
him or her. For this reason, a parent or older sibling is often the object
of imitation by the child. For children in the elementary and junior high
school age group, individuals slightly older, are important role models.
For adolescents, the peer group ,is the major source of role models.
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B) Possible outcome:
If the outcome is good and pleasing such as reward ,than chances of
repeating the behavior is more than if it is bad.
•Observational learning can be an
important tool in management of
dental treatment.
• If a young child observes an older
sibling undergoing dental treatment
without complaint or uncooperative
behavior, he or she is likely to imitate
this behavior.
•If the older sibling is observed being rewarded, the younger child will
also expect a reward for behaving well.
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•Research has demonstrated that one of the best predictors of how
anxious a child will be during dental treatment is how anxious the
mother is.
•A mother who is calm and relaxed about the prospect of dental
treatment teaches the child by observation that this
is the appropriate approach of being treated,
whereas an anxious and alarmed mother tends to
elicit the same set of responses in her child.
•Observational learning can be used to advantage
in the design of treatment areas. At one time, it
was routine for dentists to provide small private
cubicles in which all patients, children and adults,
were treated. The modern trend, particularly in
treatment of children and adolescent, is to carry
out dental treatment in open areas with several treatment stations.
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•Sitting in one dental chair watching the dentist working with someone
else in an adjacent chair can provide a great deal of observational
learning about what the experience will be like.
•Direct communication among patients
, answering questions about exactly
what happened, can add even further
learning.
• Both children and adolescents do
better , if they are treated in open
clinics rather than in private cubicles,
and observational learning plays an
important part in this.
•The dentist hopes, of course, that the
patient waiting for treatment observes
appropriate behavior on the part of
the patient who is being treated.
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•Described by the Russian physiologist Ivan Pavlov, who discovered
during his studies of reflexes that apparently unassociated stimuli
could produce reflexive behavior.
•Pavlov's classic experiments involved the presentation of food to a
hungry animal, along with ringing of a bell. The sight and sound of
food normally elicit salivation by a reflex mechanism. If a bell is rung
each time food is presented, the auditory stimulus of the ringing bell
will become associated with the food presentation stimulus, and in a
relatively short time, the ringing of a bell by itself will elicit salivation.
Classical conditioning, operates by the simple process of association
of one stimulus with another, and some times also referred as learning
by association.
CLASSICAL CONDITIONING THEORY – IVAN PAVLOV 1927
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•Classical conditioning can have a considerable impact on a young
child's behavior on the first visit to a dental office. By the time a
child is brought for the first visit to a
dentist, it is likely that he or she would
have had many experiences with
pediatricians and medical personnel.
•When a child experiences pain, the reflex
reaction is crying and withdrawal.
•In Pavlovian terms, the infliction of pain
is an unconditioned stimulus, but a number
of aspects of the setting in which the pain
occurs can come to be associated with
this unconditioned stimulus
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•If the unconditioned stimulus of painful treatment comes to be
associated with the conditioned stimulus of white coats, a child may
cry and withdraw immediately at the first sight of a white coated
dentist or dental assistant.
•In this case, the child has learned
to associate the unconditioned
stimulus of pain and the
conditioned stimulus of a white
coated adult, and the mere sight
of the white coat is enough to
produce the reflex behavior
initially associated with pain.
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CLASSICAL CONDITIONING
First visit
White coat Pain of injection
(Neutral stimulus) (Unconditioned stimulus)
Pain of injection Fear and Crying
(Unconditioned stimulus) (Response)
Second visit
Sight of white coat Pain of injection
(Conditioned stimulus) (Unconditioned stimulus)
Pain of injection Fear and Crying
(Unconditioned stimulus) (Response)
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Associations of this type tends to become:
A) Generalized:
•Painful and unpleasant experiences associated with medical
treatment can become generalized to the atmosphere of a physician's
office, so that the whole atmosphere of a waiting room, receptionist,
and other waiting children may produce crying and withdrawal after
several experiences in the physician's office, even if there is no sign
of a white coat.
•Because of this association,
behavior management in
the dentist's office is easier
if the dental office looks
different from the typical
pediatrician's office or
hospital clinic.
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B) Discrimination:
•If a child is taken into other office settings which are somewhat
different from the one where painful things happen, a dental
office, for instance, where painful injections are not always
necessary, a discrimination between the two types of offices soon
will develop and the generalized response to any office as a place
where painful things occur will be extinguished.
•In practices where the dentist and auxilaries work with young
children, they have found that it is helpful in reducing children's
anxiety if their appearance is different from that associated with
the physician.
• It also helps if they can make the child's first visit as different as
possible from the previous visits to the physician. Treatment that
might produce pain should be avoided if at all possible on the first
visit to the dental office.
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C) Strengthened or reinforced:
•Every time a child is taken to a hospital clinic where something
painful is done, the association between pain and the general
atmosphere of that clinic becomes stronger, as the child
becomes more sure of his conclusion that bad things happen in
such a place.
D) Extinction:
•If the association between a conditioned and an unconditioned
stimulus is not reinforced, the association between them will
become less strong, and eventually the conditioned response
will no longer occur.
•This phenomenon is referred to as extinction of the conditioned
behavior. If the conditioned association of pain with the doctor's
office is strong, it can take many visits without unpleasant
experiences and pain to extinguish the associated crying and
avoidance.
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•Burrhus Frederic Skinner was
born on March 20, 1904, in
Pennsylvania
•He got his masters in psychology
in 1930 and his doctorate in 1931
from Harvard.
OPERANT CONDITIONING THEORY – SKINNER 1938
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•The basic principle of operant conditioning is that the consequence
of a behavior is in itself a stimulus that can affect future behavior.
• In classical conditioning, a stimulus leads to a response; in
operant conditioning, a response becomes a further stimuli.
•The general rule is that if the consequence of a certain response is
pleasant, that response is more likely to be used again in the future;
but if a particular response produces an unpleasant consequence,
the probability that response being used in the future is diminished.
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Skinner described four basic types of operant conditioning
distinguished by the nature of the consequence .
A) Positive reinforcement.
If pleasant consequence follows a response, the response has
been positively reinforced, and the behavior that led to the
pleasant consequence becomes more likely in the future .
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B) Negative reinforcement:
 Involves the withdrawal of an unpleasant stimulus after a response.
Like positive reinforcement, negative reinforcement also increases
the likelihood of a response in the
future.
 The word negative merely refers to the
fact that the response that is reinforced
is a response that leads to the removal
of an undesirable stimulus.
 If behavior of the child which is
considered unacceptable by the dentist and his staff ,helps the child
to escape from dental treatment, then the behavior is negatively
reinforced and is more likely to occur the next time the child is in the
dental office. So it is important to reinforce only desired behavior,
and it is equally important to avoid reinforcing behavior that is not
desired . 85113

C) Omission :
•Involves removal of a pleasant
stimulus after a particular
response.
• For example, if a child who
throws a temper tantrum, has
his favorite toy taken away for
a short time as a consequence
of this behavior, the probability
of similar misbehavior is
decreased.
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D) Punishment:
•Occurs when an unpleasant stimulus is presented after a response. This
also decreases the probability of similar kind of behavior that prompted
punishment in the future. Punishment is
effective at all ages, not just with children.
•In general, positive and negative
reinforcement are the most suitable types of
operant conditioning for use in the dental
office, particularly for motivating
orthodontic patients.
•Both types of reinforcement increase the
likelihood of a particular behavior recurring,
rather than attempting to suppress a
behavior as punishment and omission do. Simply praising a child for
desirable behavior produces positive reinforcement, and additional
positive reinforcement can be achieved by presenting some reward. 87113

 Adolescents in the orthodontic treatment, for instance, can
obtain reinforcement from a simple pin saying, ' Worlds
greatest Orthodontic Patient" or something similar. A reward
for three consecutive appointments with good behavior is
another simple example of positive reinforcement .
 Negative reinforcement, which also accentuates the
probability of any given behavior, is more difficult to utilize
as a behavioral management tool in the dental office, but it
can be used effectively if the circumstances permit. If a child
is concerned about a treatment procedure but behaves well
and understands that the procedure has been shortened
because of his good behavior, the desired behavior has been
negatively reinforced.
88113

 In orthodontic treatment, long bonding and banding
appointments may go more efficiently and smoothly if the child
understands that his helpful behavior has shortened the
procedure and reduced the possibility that the procedure will
need to be redone.
 Positive or negative reinforcement becomes even more effective
if repeated, although it is not necessary to provide a reward at
every visit to the dental office to obtain positive reinforcement.
Similarly, conditioning obtained through positive reinforcement
can be extinguished if the desired behavior is now followed by
omission, punishment, or simply a lack of further positive
reinforcement.
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 Operant conditioning that occurs in one situation can also be
generalized to similar situations. For example, a child who has
been positively reinforced for good behavior in the
pediatrician's office is likely to behave well on the first visit to
a similarly equipped dentist's office because he or she will
anticipate a reward at the dentist's also, based on an assessment
of the similarity of the situation.
 A child who continues to be rewarded for good behavior in the
pediatrician's office but does not receive similar rewards in the
dentist's office, however, will learn to discriminate between the
two situations and may eventually behave better for the
pediatrician than for the dentist.
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IMPLICATICATIONS OF PSYCHOLOGY
IN ORTHODONTICS
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Psychological Management of Orthodontic Patient:
Young child (6 to 9 yrs)
• Same approach for both boys and girls.
• Natural curiosity of school days makes their attention readily
available.
• The best method for obtaining
cooperation is to actively teach the
child the purpose of your treatment.
• Careful explaination about what you
intend to do and a brief why, using
language that the child can
understand.
• This may be supplemented with
charts, simple stories which the child
can read himself or short single concept films.
92113

• Children of this age are natural imitators. They tend to do almost
anything they are told to do, particularly if it is with precise
directions. This is why most children of this age respond well to
tooth brushing charts and tables
which allow them to see how well
they are progressing. This, in
effect, is a simplified teaching
machine.
• Praise should be given freely as a
means of re-enforcement. The
bribe of a toy for good behavior
from the dentist decreases their
desire to know what is
happening to them. Bribery should
therefore not be used.
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It is difficult to use removable appliances in children from six to
nine.
• In the early mixed dentition when undercut areas for appliance
retention are hard to find.
• They are learning to articulate adult speech patterns.
• They are attempting to break their infantile habits of digital
sucking and tongue thrusting.
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Early Adolescent (ten to thirteen yrs) : Boys:
• Retains his curiosity about the "why" of treatment during this
period, but the "how" begins to capture his imagination.
• He is fascinated by scientific instruments and mechanical gadgets.
• To gain cooperation from a boy of this age group, one must show
interest in his interests. One must again be careful to explain each
procedure to the child and why. "Show and tell" explanations will
lead him to ask "how do you do that, or how does this machine
work?". Let him observe operative procedures through a hand
mirror. Allow him to hold some materials such as periphery wax,
alginate or blunt hand instruments. If he seemed quite excited by
this, the reward of a trip to the laboratory will turn the young
patient into a fast friend.
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Female :
• Quite different from the boy but an equal challenge.
• She is passionately interested in her developing body. Any dental
procedure that might affect her looks is accepted.
• She is very susceptible to flattery which can lead to the ''crush
syndrome" which can be a management problem.
• She is very gossipy . Efforts to establish rapport through
conversation can end up as a talked away appointment.
• Friendliness may be demonstrated by a smile and a compliment on
behavior or an achievement.
• The conversation should be brief, pleasant, impersonal and
thoughtful. 96113

The Teenage (fourteen to eighteen yrs) :Male:
• Express the adult image which is usually overtly uncomfortable for
him.
• He wishes to be treated as an adult
but often express himself as an
irrational child .
• His interests have now narrowed
to normal development of his body,
acceptance by his peers. He spends hours primping himself in the
mirror. He is desperately fighting anything that makes him look
different from the group with whom he identifies.
• Management of the teenage male is by sympathy and
understanding.
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• Trust is the most valuable asset to be sought from this age group.
• It is important that treatment plans be discussed with the same
logic, responsibility and firmness, as with an adult patient. This
allows the boy to assume the adult role which will soon be reality.
• If discipline becomes a problem the dentist has an advantage. He
is an authority figure outside the family. The chances are good
that a boy will readily discuss why he is not following your
instructions
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Female :
• She is conscious about her appearance and peers .She wants to be
as proportional as her peers.
• Orthodontic appliances offer a threat to her immediate body
image or, if she has an unaesthetic malocclusion, they offer a
promise.
• The trust in management must be toward the cosmetic and status
value.
• Once trust is established, she will usually be cooperative , due to
her earlier maturity. Discipline should again be handled by
discussing the root of the problem and its various solutions rather
than making “parent like” demands for cooperation.
• Latent crush syndromes can occur in this age group, particularly
in girl with the unaesthetic malocclusion. The orthodontist is
freeing her of her problem. He takes on the proportions of a hero.
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• They are trying to assume the role of an adult and they do not
believe their parents have an understanding of any of their
problems. Therefore detailed consultations and progress reports
should be given to the parent and child, but separately.
• The patient will take comfort in knowing that her parents are
concerned about her treatment, but the patient will take offense if
she feels they are directing it. The primary relationship is with the
child and not with the parents.
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Psychological timing of orthodontic treatment-by-
Jay Weiss:AJO-1977
• A questionnaire type of study was undertaken to test the
hypothesis that prepubescent patients are more cooperative than
adolescents.
• Older children were found to be psychologically resistant to the
demands of orthodontic treatment because of their involvement in
Oedipal conflicts, a normal but distracting aspect of "growing up.“
• Study found that patients under 12 were more cooperative than
other age groups in the wearing of headgear and other removable
devices but they were less cooperative in keeping appointments or
in protecting appliances from breakage.
• The study suggests that, from a psychological standpoint, activator
and headgear treatment should be begun sometime after age 6 and
soon enough to be completed before the onset of puberty.
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• Children at this stage still are not likely to be motivated by
abstract concepts such as "If you wear this appliance your bite
will be better." They can be motivated, however, by improved
acceptance. This means that emphasizing how the teeth will look
better as the child cooperates is more likely to be a motivating
factor than emphasizing a better dental occlusion.
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Psychological and Social effects of orthodontic
treatment by Judith E. N. Albino
• Adolescents with commonly occurring forms of malocclusion often
are presumed to be at risk for negative self-esteem and social
maladjustment.
• A randomized control group design was used to assess the
psychosocial effects of orthodontic treatment for esthetic
impairment. Ninety-three participants, 11 to 14 years old, with min
to moderate malocclusions, were randomly assigned to receive
orthodontic treatment immediately or after serving as delayed
controls.
• A psychological and social measures was administered before
treatment, during treatment, and three times after completion of
treatment, the last occurring one year after termination.
Journal of Behavioral Medicine,Vol. 17, No. 1, 1994
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• Repeated measures analyses of variance assessed group differences
at the five time points.
• Parent, patient, and self-evaluations of dental-facial attractiveness
significantly improved after treatment, but treatment did not affect
parent and self-reported social competency or social goals.
• In summary, dental-specific evaluations appear to be influenced by
treatment, while more general psychosocial responses are not.
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Psychological aspects of orthodontics in clinical
practice by Ali Ukra:
•The orthodontist-patient relationship may have a significant impact
on treatment outcome and patient satisfaction, thus improving the
overall quality of care.
•Effective communication is crucial and unfortunately, it is often not
possible in a busy clinical practice.
•The psychological aspects that are relevant to a number of treatment
variables in clinical orthodontics, including compliance with
treatment, oral hygiene, management of orthodontic pain and
discomfort, and oral habits.
progress in orthodontics 1 2 (2011) 143
105
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•Due to the complex nature of the psychology of orthodontic
treatment, it is difficult to determine the extent of the influence that
the orthodontist-patient relationship may have on these variables,
with effective communication and an awareness of the
psychological issues plays an important role in enhancing the
orthodontist-patient relationship.
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•The relationship between physical esthetics and positive social
interaction has long been reported in the dental, psychological, and
social science literature.
•Attractive facial appearance in young children was found to be the
most influential of 33 different characteristics for social acceptance
and popularity among peers by Young and Cooper .
•The perception that attractive individuals are more intelligent and
more qualified at task completion has been reported in several
studies.
CONCLUSION
Age Appropriate OrthodonticTreatment: Psychological Considerations
Semin Orthod , 2014
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•The qualitative judgment of facial appearance by an individual and
others is shown to affect self-image and self-perception with an
impact on educational and social opportunities.
•Negative social interactions such as teasing and bullying due to
facial appearance are strong motivators for children and parents to
seek orthodontic treatment.
•Selfimage and self-esteem seem inextricably linked to children’s
perception of their dental appearance
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Age Appropriate OrthodonticTreatment: Psychological Considerations
Semin Orthod , 2014

•Patients and parents place trust in orthodontist when they seek
treatment. They rely on us to tell them if the treatment is essential.
•All patients will not finish treatment successfully. This is not our fault
always. Lack of patient co-operation and vagaries of growth sometimes
mitigate success.
•It is an alert orthodontist who recognizes the emotional reactions of
the patient and not only treating malocclusion but also psychological
fears, frustrations and behavior.
•The principle of knowing as much as possible about the patient, his
family and his environment is a must that all practitioners should keep
in mind, for dentistry, and like medicine, recognizing the therapy is not
really successful unless the whole patient is treated.
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REFERENCES
•Dentistry for the child and adolescent. Eighth edition. Mcdonald.
Avery. Dean
•Child management in the dental office. Clinical pedodontics. Fourth
edition. Sydney B Finn.
•Textbook of pedodontics, 2nd edition - by Shobha tandon
•Textbook of paediatric dentistry by - Damle
•Paediatric Dentistry: Principles and Practice, 2nd edition -
•by M. S. Muthu, Shiva Kumar
•Louis Norton. Psychological Management of Orthodontic Patient, AO
July 1971,, Vol 41, No 3
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•Jay Weiss. Psychological timing of orthodontic treatment,
AJO 1977,, Vol 72, No 2
•Seema Grover. Psychological aspects of orthodontic
treatment, JIOS 2001 Vol 34
•Alice W. Tung. Psychological influences on the timing of
orthodontic treatment, AJODO 1998,, Vol 113, No 1
•Judith E. N. Albino. Psychological and Social effects of
orthodontic treatment, Journal of Behavioral Medicine 1993,,
Vol 17, No 1
•Alex Jacobson. Psychology and early orthodontic treatment,
American association of Orthodontics 1979.
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•Ali Ukra. Psychological aspects of orthodontics in clinical
practice, Progress in Orthodontics 2011,, Vol 12, No 2
•Maxims or myths of beauty? A meta analytic and theoretical
review. Psych Bull 2000; 126:390- 423.
•Nordholm LA, Beautiful patients are good patients: evidence
for the physical attractiveness stereotypes in first impressions of
patients. Soc Sci Med 1980; 14: 81-83
•Age Appropriate Orthodontic Treatment: Psychological
Considerations Semin Orthod , 2014
•
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Erik Erikson’s Theory of Psychosocial Development, MAY
2019

The treatment may be perfect, BUT
The appointment is a failure if the
patient departs in tears.
THANKYOU!!!
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psychological management of orthodontic patient

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