This presentation discuss about emotional development of a child at various stages of life

1. DEPARTENT OF PEDIATRIC & PREVENTIVE DENTISTRY
BDS FourthYear lecture
Dr. Rishabh Kapoor
Reader (Pediatric and Preventive Dentistry)
29/4/2024

2. Teaching Objectives
• To introduce students to the concept of emotional development in children
• To give a brief review of emotions and their implication during dental procedures
• Types of fear, anxiety and phobias that develop or persist in children

3. CONTENTS
• Introduction
• Definition
• Types of emotions
• Important of Emotional Development
• Physiology of emotion
• Characteristics of commonly seen emotion in a child
• Distress or Cry
• Anger
• Fear
• Anxiety
• Phobia

4. Introduction
• Each of us is born into society with rules, expectations, attitudes, and
values.
• Our task throughout development is to come to understand ourselves, how
we feel and function, and what our society deems desirable and
appropriate.
• The emotional development of children and adolescent represent a huge
variation according to age, maturity, intellectual development,
temperament, experience, family background, cultural background etc.

5. • These factors play an important role in influencing the child’s
development and underlying emotions.
• Concurrently, these aspects influence the child’s ability to cop with
dental treatment.
• According to their age and emotional development some children
remain calm during the treatment , while others are vulnerable and
may need more attention and time in order to make them cooperate for
dental treatment.

6. Definition
• Emotion: An effective state of consciousness in which
joy, sorrow, fear, hatred or the likes are expressed.
• Emotional development is the developmental process of
the child’s ability, to control their feelings.

7. Good Emotions
• Contentment,
• Humor,
• Eagerness,
• Love,
• Delight
Negative Emotions
• Anger,
• Jealousy,
• Fear,
• Hate,
• Sadness,
• Depression

8. IMPORTANCE OF EMOTIONAL DEVELOPMENT
• Better
understanding of the
child
•To understand the
problems of
psychological origin
• Deliver dental
service in a
meaningful manner
• Establish effective
communication.
Gain confidence of
child & parents
• Better teaching of
primary & preventive
care
• Effective
treatment planning
and execution
• Provide a
comfortable
environment

9. Emotional security = Happy child
POSITIVE MOTION
Affection, amusement, joy,
curiosity and happiness
Essential to normal
development.
NEGATIVE EMOTION
Fear, anger, jealousy
Harmful to
development

10. Infancy Early adulthood Late adult hood
Distress Anxiety Grief
Startle response Fear Worry
Shame Self pit
Anger Guiltyfeeling
Disgust Depression
Jealousy Irritability
Disappointment boredom
Restlessness
Joy
Delight Elation Mystical
Hopeful anticipation Ecstasy
Affection Possessive
Satisfaction
Benevolence
Different emotions at different stages of life

11. PHYSIOLOGY OF EMOTION
• Development of emotion depends on maturation in the
nervous system and the endocrine system.
• Differences in emotional responsiveness between children
and adults appear to be partly due to cortical immaturity
and partly due to difference in endocrine out put.
• At the birth cortex development is completed, frontal lobe is
immature and has little influence on the functions of the lower
part of he brain resulting in imbalanced emotion.
• Hence, emotional response of the child is quickly aroused but short
lived

12. • The sympathetic system is active
during aroused states and prepares
the body for extensive action by
increasing the hart rate, blood
pressure, blood glucose level and
raising the level of certain hormones
in the blood.
• Parasympathetic systems, tends to be
active when we are calm and relaxed.

13. Characteristics of commonly seen emotion in a child
• Distress or Cry
• Anger
• Fear
• Anxiety
• Phobia

14. Distress or Cry
• The most common way a child expresses fear is by crying at the dentist’s
office.
• Crying, like other emotional manifestations of human behaviour is an
expression of personality of an individual.
• It is the result of conflict with the developing ego and with his newly found
interests.
• After the age of one and a half child develops a variety of fears and cries
for the security of his mother’s company

15. At birth:
• Primary emotion
• With vigorous body expression
• Usually due to hunger , colic or any internal cause.
At six months
• Greatly replaced by a milder expression of fussing or vocalization
During preschool:
• Only for the reason of physical pain as he is disappointed by his environment
During school year:
• pressure helps him to outgrow the crying habit which decrease rapidly.
• After this till 15 years crying occurs very seldom
In young adult:
• limited to quiet crying in private only for reason of grief or other intense emotion

16. Type of cry seen in children
Obstinate
cry
Frightened
cry
Hurt cry
Compensato
ry cry
Following four type of crying are usually seen in children (Elsbach, 1963)
Obstinate cry
• The child throw a temper tantrum to thwart dental treatment
• It is loud, high-pitched
• Pause and repeated over and over again.
• Characterized as a siren like wail
• Represents the child’s external response to anxiety
Frightened cry
• Usually accompanied by a torrent of tears.
• Convulsive breath-catching sobs
• Usually the child emitting this type of cry has been overwhelmed by the
situation.
Hurt cry
• May be loud and more frequent.
• Frequently accompanied by a small whimper
• Initially a child in discomfort shows a single tear filling the corner of the
eye and running down the child’s cheek with out making any sound or
resistance to the treatment procedure.
Compensatory cry:
• It is not a cry at all
• It is a sound that child makes to drown out the noise, for example, a drill.
• Usually the cry sound is slow, monotone.
• It is a sort of coping mechanism to unpleasant auditory stimuli, finding himself
uncomfortable in the situation.

17. ANGER
• Outburst of the emotion is caused by the child’s lack of skill in handling
the situation.
• Infant and young children respond in anger in a direct and
primitive manner but as they develop, the responses become violent
and more symbolic.

18. 15 months children express anger by throwing objects.
2- year olds attack other children with an intention to hurt.
4 yrs- express their anger through begging.
5 yrs- less expression of anger.
6 yrs - olds have a renewal of violent method of expression of anger.
7 yrs- display less aggressiveness, through kicking, throwing objects is observed.
8-9 yrs - anger is expressed through feelings. It become directed towards a single person.
10 yrs - anger may become violent and may be expressed physically.
12 yrs - express anger verbally.
14 yrs - may take out his anger on someone else.

19. FEAR….
• Fear is a reaction to a known danger (augmenting the fight or flight response)
• Def: An unpleasant emotion or effect consisting of psychological changes in
response to realistic threat or danger to one’s own experience.
• Dental fear (DF) is a normal emotional reaction to one or more specific
threatening stimuli in the dental situation

20. By association
with native or
previously
acquired fear.
By direct
imitation of a
person who
manifests fear.
By the aftermath
of an unpleasant
experience
(directly or
indirectly related
to the dental
experience).
FEAR ARISES IN ONE OF THE THREE WAYS

21. THE CHILD’S FEARS CHANGES WITH AGE
Children aged 2-3 years are more reactive to
immediate situation and fear parental separation,
strange environments and new situations.
Fears of 4-8 years old children are related to prior
situations and experiences. They begin to anticipate
situations and react with fear.
By 9 years of age fear is usually associated with
personal failures and social peer situations.

22. TYPE OF FEAR
INNATE
FEAR
SUBJECTIVE
FEAR
OBJECTIVE
FEAR

23. INNATE FEAR 
• without stimuli or previous experience
• Dependent on the vulnerability of the individual
OBJECTIVE FEAR
• Produced by direct physical stimulation of the sense organs
and are generally not of parental origin.
• Objective fears are responses to stimuli that are felt, seen,
heard, smelled or tasted, and are of a disagreeable or
unpleasant nature.
SUBJECTIVE FEAR
• Fear based on somebody else’s experience without actually undergoing dental
treatment himself.
• The majority of the children who visit the dentist are anxious in particular
during first visit.
• Their anxiety level may be heightened by stories from friends, relatives, parents
who have threatened them using dentist’s visit as punishment for bad behavior.

24. SUGGESTIVE FEARS
acquired by imitation by observation of other
IMITATIVE FEARS
transmitted while displayed by other
(parent) and acquired by the child
without being aware of it. Displayed
emotion in parent’s face creates more
impression than verbal suggestions.
•Even a tight clenching of the child’s
hand in dental office while undergoing
dental treatment creates fear in child’s
mind about dental treatment.
IMAGINATIVE FEARS
as the child’s imaginative capability
develop, they become more intense with
age.

25. Value of fear
• Fear lowers the threshold of pain so that every pain produced during
the dental treatment becomes magnified.
• Since fear producing stimuli can cause actual harm to the child, fear
is protective mechanism for self protection.
• The nature of fear can be utilizes to keep the child away from dangerous
situation of either social or physical nature.
• The child should be taught that dental office is not a place to fear.
• Dentistry should not be employed as a threat or punishment using it in
this manner creates fear of dentistry or dentist.
• On the other hand, if the child has become attached to the dentist, fear
of loss of his approval may have some value in motivating the child for
dental treatment.

26. FEAR EVOKING DENTAL SITUATION
26
Fear due to strange environment and people
Fear due to past memories of doctors, medical people
Fear due to negative preparation at home
Fear due to imagination of painful outcome
Fear associated with past negative dental experience
Fear of noises
Fear of sharp instruments, needles

27. Factors causing
dental fear
Fear of pain
or its
anticipation
Fear of
betrayal or
A lack of
trust
Fear of
loss of
control
Fear of the
unknown
Fear of
intrusion

28. PHYSIOLOGICAL SIGNS OF FEAR
Hair standing on end
Dilation of pupils
Rapid breathing
Increased heart rate
Rising blood pressure
Contraction of bladder and rectum
Pale sweaty skin
SYPTOMS OF INTENSE FEAR
Unpleasant feeling of terror
Pounding of the heart
Tense muscle
Liability to startle
Dryness of throat and Mouth
Sinking feeling
Nausia feeling
Urge to urinate
Irritability
Anger
Weakness
Sense of unreality

29. Behavioral treatment of fearful children
• Communication
• Euphemisms
• The guidance cooperation model
• Time-structuring
• Distraction
• Guided imagery
• Behavior modification
• Parent in operatory

30. ANXIETY
• Is an emotion similar to fear but arising without any objective source
of danger.
• Is a reaction to unknown danger.
• It is a learned process being in response to one’s environment.
• As an anxiety depends on the ability to imagine, it develops
later than fear.

31. TYPES OF ANXIETY
Trait anxiety
• It is life-long pattern of anxiety as a temperament feature.
• These children are generally jittery, skittish, and hypersensitive to
stimuli.
State anxiety
• These are acute situational-bound episode of anxiety that do not persist
beyond the provoking situation.
• Examples: A child feels anxious when confronted by a large, strange
animal. A person feels anxious to get on an airplane for the first time.

32. Free floating anxiety:
• It is condition of persistently anxious mood in which the cause of
emotion is unknown and many other thoughts or event trigger the
anxiety.
Situational anxiety:
• It is only seen in specific situations or objects.
General anxiety:
• where the individual experiences a chronic pervasive feeling of
anxiousness, whatever may be the external circumstances.

33. CAUSEOF ANXIETY
Uncertainty
• Fear of unknown is anxiety provoking.
• In dental clinic new patient’s anxiety can be due to uncertainty they feel about
what await them after initial first appointment check up.
Previous learning
• anxiety is present due to their previous learning experiences of trauma during the
first visit or the learning involved in dental anxiety may have been more indirect,
depending upon the experience of other people.
• Maternal anxiety directly relates to child’s anxiety.
• A mother with higher anxiety will have a child usually showing a negative behavior
as a result of his/her high level of anxiety.
Biological difference:
• Some people are more predisposed to become more anxious or
to learn about anxiety responses than other due to the innate
biological mechanism.

34. Dental anxiety and its implications for
paediatric dentists
• With regard to paediatric dentistry, it is important to keep in mind that
anxious patients manifest their anxiety in different ways. Some can
respond with disruptive or interruptive behavior.
• Others can respond by sweating and an increased heart rate, whereas
other patients do not show any external sign of anxiety

35. • Dental anxiety, and the avoidance of situations that involve dental
treatment and care, have frequently been considered to be the source of
serious oral health problems in children and adults.
• High levels of anxiety prevent a patient from cooperating fully with their
dentist, most importantly, can limit the effectiveness of the dental
treatment and prevent the early detection of pathological processes

36. Methods of assessing dental anxiety

37. PHOBIA
• Is an irrational fear resulting in the conscious avoidance of a specific
feared object, activity or situation.
• It may be defined as a persistent, excessive, unreasonable fear of a
specific object, activity or situation that results in a compelling desire
to avoid the dreaded object.

38. Characteristics of phobia
• Being out of proportion to the stimulus or situation
• Cannot be reasoned with
• Being out of voluntary control
• Persistent and inadaptable.
Shelhan (1982) divided anxiety and phobia into two major group:
1 endogenous
2. exogenous ( non – endogenous)

39. Non-endogenous (exogenous)
This is a psychologically affected group which involves situation
related anticipatory anxiety symptoms such as :
 Moist palms
 Fluttery stomach
 Fine hand tremor
 Shaky inside
 Rapid hart beat

40. • These are the symptoms seen when normal individuals are
arrested or threatened.
• the main cause is in the external environment
• It is an anxiety or phobia due to a factor “to be produced from
the outside”.
• Thus, the individual can readily identify the etiological agent.

41. Endogenous:
• This anxiety is present without prior warning or the presence of ay detectable
stress situation.
• The cause is “to be produced from within”.
• This type of anxiety has a more severe cluster of symptoms such as:
 Light headedness or dizziness
 Difficulty in breathing
 Parasthesia
 Hyper ventilation
 Chest pain
 Losing control

42. • Acrophobia – height
• Agoraphobia – open space
• Arachnophobia – spider
• Anthrophobia – people
• aquaphobia – water
• Astraphobia – lightening
• Claustrophobia – closed space
• Cynophobia – dog
• Zoophobia – Animals
• Nyclophobia – darkness
• Pyrophobia - fire
• Xenophobia – stranger
SIMPLE PHOBIAS
•Isolated fear of a single object or situation leading to avoidance of the object or the
situation.
•The fear is irrational and excessive, but not always disabling.

43. SITUATIONAL PHOBIA
• Is popularly interpreted as a fear of open space, but has wider implication.
• It usually refers to a cluster of complaints.
• In addition to open or crowded places they also fear public transport,
bridges, tunnels, benign alone at home or being away from home etc.
• Characteristics
• Dizziness, loss of bladder control or bowel control, cardiac
distress.
SOCIAL PHOBIA
• It is basically phobia due to the fear of being looked at and the
concern about appearing shameful or stupid presence of other
• Main types of social phobia are public speaking, fear of eating,
fear of blushing.

44. Phobia in childhood:
• The most common phobia in childhood is the fear of animal.
• This usually comes on between the age of 2 and 4 and is gone
before the age of 10 years.
• Another common phobia is of darkness, a fear experienced by
children between the age of 4 and 6 years.
• This is most likely due to the imagination of the child as to
various creature lurking out in the dark.
• School phobia is an exaggerated fear of attending school and occurs in all
children peaking around 11-12 years.
• A fear of the various activities connected to school such as new faces
and challenges, fear of leaving home.
• In 12 years children of both sexes, previous aversive dental experiences
are more closely related to dental phobia than general fear.
• At adolescent period most children outgrow their fear.
• Two phobias commonly seen are fear of blushing and fear of being looked
at.

45. VIDEO LINK
https://www.youtube.com/watch?v=pXqwWvzNykE
https://www.youtube.com/watch?v=VXf7Wy1mYlU

46. CONCLUSION
 Dentally anxious/fearful children present a considerable challenge to
parents, dentists and initial identification of such children is important
in order to shorten involvement time, to allow the dentist to
acknowledge their limitations, and to avoid frustration for the dentist
and the patient.
 Uncooperative children have a special need, or a disability that requires
proper knowledge and special attention during treatment.

47. REFERENCES:
 Dentistry for child and adolescent - Ralph E Mc Donald
 Text book of Pediatric Dentistry - S.G.Damle
 Text book of Pedodontics - Shobha Tandon
 Text book of Pediatric Dentistry - Nikhil Marwah

48. SUGGESTED READING
 Pediatric Dentistry: Infancy Through Adolescence (6th Edition): Arthur J. Nowak
Text book of Pedodontics - Shobha Tandon

49. University Questions
Short note on
1. Fear - September 2012 (03 marks)
SuggestedQuestions
Short note on
Phobias
Types of Cry

50. MCQs
1. Which of the following is not seen in infancy
a) Distress
b) Anxiety
c) Startle response
d) Delight
3. Loud pitched noise in which the child throws
temper tantrum with a siren like wail, this is :
a) Obstinate cry
b) Frightened cry
c) Hurt cry
d) Compensatory cry
2. Reaction to unknown danger is
a) Fear
b) Anxiety
c) Both of the above
d) None of the above
4. Causes of anxiety are:
a) Uncertainty
b) Previous learning
c) Biological differences
d) None of the above