Child psychology /certified fixed orthodontic courses by Indian dental academy

CHILD PSYCHOLOGY

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CHILD PSYCHOLOGY
INDIAN DENTAL ACADEMY
Leader in continuing dental education


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Contents
Introduction
Classification of basic theories
Psychosexual Theory
Psychosocial Theory
Cognitive Theory
Social Learning Theory
Classical Learning Theory
Operant Conditioning Theory
Child Management
Conclusion
References

INTRODUCTION
"At first glance, the disciplines of psychology and clinical
orthodontics would seem to be as separate as any two
disciplines one could find. It has been stated that 'One is
mental, the other is dental'. Indeed, it is difficult to bring
these two sciences together. One involves clinical
treatment; the other is a social science. The clinician
measures physical characteristics with direct precision in
terms of millimeters and degrees; the psychologist
measures less specific entities, such as verbal social
actions and attitudes. Yet while these two sciences appear
to be dichotomous, there are areas of overlap where
interdisciplinary considerations are both useful and
necessary." Dr T.M. Graber .

Classification of psychological developmental
theories
• Psychodynamic Theories:
• Psychosexual Theory –Sigmund Freud
• Psychosocial Theory-Eric Erickson
• Cognitive Theory- Jean Piaget
• Behavioral Learning Theories:
• Social Learning Theory-Albert Bandura
• Classical Conditioning Theory-Ivan Pavlov
• Operant Conditioning Theory-Skinner

Psychosexual Theory-Dr. Sigmund Freud(1905)


• What is Psychosexual Development?

• According to Freud, personality is mostly
established by the age of five. Early experiences
play a large role in personality development and
continue to influence behavior later in life.
Freud believed that personality develops through a
series of childhood stages during which the
pleasure seeking energies of the id become
focused on certain erogenous areas. These
psychosexual energies, or libido, were described
as the driving force behind behavior.

• The Structural Model of Personality:
• According to Freud’s psychoanalytic theory of
personality, personality is composed of three
elements. These three elements of personality
are known as the id, the ego, and the superego
which work together to create complex human
behaviors.


• The Id
• The id is the only component of personality that is
present from birth
• This aspect of personality is entirely unconscious
and includes of the 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 anxiety or
tension.

• 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.

• 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.

• 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.

• 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:
• 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.

• The conscience- includes information about things
that are viewed as bad by parents and society. These
behaviors are 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.

• The Interaction of the Id, Ego, and Superego
With so many competing forces, it is easy to see
how conflict might arise between the id, ego, and
superego. Freud used the term ego strength to
refer to the ego’s ability to function despite these
dueling forces. A person with good ego strength is
able to effectively manage these pressures, while
those with too much or too little ego strength can
become too unyielding or too disrupting.
According to Freud, the key to a healthy
personality is a balance between the id, the ego,
and the superego.

Stages of psychosexual development
• The Oral Stage (0 to 1 yr )
• The infant’s primary source of interaction occurs through
the mouth, so the rooting and sucking 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 sucking.
• 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.

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 oralpassive 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.

• When child is between five and eight months of age
, he begin teething. 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, person may develop an oralaggressive personality. These people retain a lifelong desire to bite on things, such as pencils, gum,
and other people. They have a tendency to be
verbally aggressive, argumentative & sarcastic.

• 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.
• If parents take an approach that is too lenient, an analexpulsive 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, www.indiandentalacademy.com
rigid, and obsessive.

• 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.

• 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.

• 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 and, 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.


Psychosocial Theory-Eric Erickson(1963)
• Erikson is a Freudian egopsychologist. 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 cultureoriented than Freud.

The epigenetic principle
This principle says that we develop through a
predetermined unfolding of our personalities in
eight stages. Our progress through each stage is in
part determined by our success, or lack of success,
in all the previous stages.
• Each stage involves certain developmental tasks.
• The various tasks are referred to by two terms .
• Each stage has a certain optimal time as well.

• If a stage is managed well, we carry away a certain
virtue or psychosocial strength which will help us
through the rest of the stages of our lives. If we
don't, we may develop: maladaptations and
malignancies.
• A malignancy involves too little of the positive and
too much of the negative aspect of the task.
• A maladaptation involves too much of the positive
and too little of the negative

The first stage - oral-sensory stage, (Birth to 1- 1/2 yr)
The task is to develop trust without completely
eliminating the capacity for mistrust.
• If mom and dad 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, are there the
minute the first cry comes out, will lead that child into the
maladaptive tendency of sensory maladjustment.

• 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.

• The tight bond between parent and child ,in this
early stage of emotional development is reflected as
strong sense of "separation anxiety" in the child
when separated from his parent. If it is necessary to
provide dental treatment at an early age, it usually is
preferable to do so with the parent present, and if
possible, while the child is being held by one of the
parents. At later ages, a child who never developed a
sense of basic trust will have difficulty entering into
situations that require trust and confidence in
another person. Such an individual is likely to be an
extremely frightened and uncooperative patient who
needs special effort to establish rapport and trust
with the dentist and stuff.

Stage two- anal-muscular stage
(18 months to 4 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. www.indiandentalacademy.com

• A little "shame and doubt" is not only inevitable, but
beneficial. Without it, child will develop the
maladaptive tendency called impulsiveness, a sort
of shameless that leads him to jump into things
without proper consideration of his abilities.
• Too much shame and doubt, which leads to the
malignancy of compulsiveness. The compulsive
person feels that everything must be done perfectly.
• If child get the proper, positive balance of autonomy
and shame and doubt, he will develop the virtue of
willpower or determination.

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, it is all right to open his mouth if he
want to, but almost psychologically
unacceptable to do it if someone tells him to.
One way around this is to offer the child
reasonable choices whenever possible, for
instance, either a green or a yellow napkin for
the neck.

• Stage three (3 -6 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 the reluctance 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.

• 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. The goals are everything, and guilty feelings
are for the weak.
• 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.

For most children ,first dental visit comes in this age of
initiative. Going to dentist come 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 off 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.

• Stage four- latency stage (6 to 12 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 .

• Too much industry leads to the maladaptive
tendency called narrow virtuosity. E.g. : child
actors. We all admire their industry, but if we look a
little closer, it's all that stands in the way of an
empty life.
• 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 ever try again! We become inert.
The right balance of industry and inferiority mostly industry with just a touch of inferiority to
keep us sensibly humble, then we have the virtue
called competency.

• Orthodontic treatment in this age group is likely to
involve the faithful wearing of removable
appliances. Whether a child will do so is determined
in large part by whether he or she understands what
is needed to please the dentist and parents, whether
the peer group is supportive, and whether the
desired behavior is reinforced by the dentist.


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.

• 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 or
status from the peer group. 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,
which the peer group is not likely to notice.


Stage five – adolescence
( puberty to18 or 20 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?"

• 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
especial kind of group that is particularly eager to
provide the details of their identity.
• If one successfully negotiate this stage, he will have
the virtue of fidelity. Fidelity means loyalty, the
ability to live by societies standards despite their
imperfections and and inconsistencies ,a person has
found a place in that community, a place that will
allow him to contribute.

• 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.

Approval of the peer group is extremely important. At one
time, there was a certain stigma attached to being the only
one in the group so unfortunate as to have to wear braces.
Now, orthodontic treatment has become so common that
there may be a loss of status attached to being one of the
few in the group who is not receiving treatment, so that
treatment may even be requested in order to remain "one in
the crowd."
In this stage, abstract concepts can be grasped readily, but
appeals to do something because of its impact on personal
health are not likely to be heeded. The typical adolescent
feels that health problems are concerns of somebody else,
and this attitude covers everything from accidental death in
reckless driving to development of decalcified areas on
carelessly brushed teeth during orthodontic treatment.

• Stage of young adulthood(18 to about 30yr)
• 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.

• 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." It includes not only
the love we find in a good marriage, but the love
between friends and the love of one's neighbor,
coworker etc.

• 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.


• The factors that affect the development of an
intimate relationship include all aspects of each
person—appearance, personality, emotional
qualities, intellect, and others. A significant change
in any of these may be perceived by either partner as
altering the relationship. Because or these potential
problems, the potential psychological impact of
orthodontic treatment must be fully explained to and
explored with the young adult patient before
beginning therapy

Stage seven - middle adulthood .(middle twenties to the late
fifties).
• 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.
• More obvious, of course, is the malignant tendency of
rejectivity. Too little generativity and too much stagnation
and you are no longer participating in or contributing to
society.

Stage eight - late adulthood ( as old age).
• The task is to develop ego 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.

• 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."

Cognitive Theory-Jean Piaget (1952)
• 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 thoughtprocesses , 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.


• Process of cognitive development: Piaget believed that every
individual is born with the capacity to adjust and adapt to both
physical and sociocultaral environment in which he or she live in. He
described two processes used by the individual in its attempt to adapt:
assimilation and accomodation.
• Assimilation is the process of incorporation of events within
environment into mental categories called cognitive structures or
schemas
• Accomodation is the process of changing cognitive structures to better
represent the environment. Both processes are used simultaneously
and alternately throughout life.
• As schemes become increasingly more complex (i.e., responsible for
more complex behaviors) they are termed structures. As one's
structures become more complex, they are organized in a hierarchical
manner (i.e., from general to specific).

• Assimilation and accommodation work like a
pendulum, swings at advancing our understanding
of the world and our competency in it. They both are
directed to attain a balance between the structure of
the mind and the environment, and that ideal state is
called as equilibrium.
• As Piaget continued his investigation of children, he
noted that there were periods where assimilation
dominated, periods where accommodation
dominated, and periods of relative equilibrium, and
that these periods were similar among all the
children he looked at in their nature and their
timing. And so he developed the idea of stages of
cognitive development.

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: She may squeeze a rubber duckie. It goes
quack. That is great, so do it again, and again. She is
learning procedures that make interesting things last.

• Between 12 months and 24 months, the child works
on tertiary circular reactions. They consist of the
same making interesting things last cycle, except
with constant variation. I hit the drum with the stick
-- rat-tat-tat-tat. I hit the block with the stick -thump-thump .I hit daddy with the stick -- ouchouch. 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, 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.

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.

• 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, she 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, she 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. www.indiandentalacademy.com

Mom, cut it into a
lots of slices ,I
am really hungry


• 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."

• 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 have only little problem in getting the
child to accept the idea that "Mr. Thumb" was the
problem and that the dentist and the child should form a
partnership 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.

• 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 was
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.

•

•
•
•

Concrete operations stage ( 7 to11 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.
The stage begins with progressive decentering.
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: If we pour the milk from the short, fat glass into
the tall, skinny glass, he will tell us that there is the same
amount of milk as before, despite the dramatic increase in
milk-level!

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 masteredconservation 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! www.indiandentalacademy.com

• 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 old toothbrush to keep it clean”.

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
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. 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

• 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.

• 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 be ‘ in the crowd’.
• 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”.
• This concept holds that “because I am unique, I am not subject to the
consequences others will experience."

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.
• A teenage patient may protest to his orthodontist
that he does not want to wear a particular
appliance because others will think it makes him
"look goofy." In this situation, telling the patient
that he should not be concerned because many of
his peers also are wearing this appliance does
little to encourage him to wear it.

• A more useful approach is that do not deny the point
of view of the patient , agree with him that he may
be right in what others will think, but ask him to
give it a try for a specified time. If his peers do
respond as the teenager predicts, then a different,
but less desirable treatment technique can be
discussed. This test of the teenager's perceived
reality usually demonstrates that the audience does
not respond negatively to the appliance or that the
patient can successfully cope with the peer response.

• Criticisms of Psychodynamic Approaches
• Freud’s theories overemphasized the unconscious mind,
aggression, and childhood experiences.
• Many of the concepts proposed by psychodynamic
theorists are difficult to measure and quantify.
• Strengths of Psychodynamic Approaches
• While most psychodynamic theories did not rely on
experimental research, the methods and theories of
psychodynamic thinking contributed to experimental
psychology.
• Many of the theories of personality developed by
psychodynamic thinkers are still influential today,
including Erikson’s theory of psychosocial stages and
Freud’s psychosexual stage theory.

Social Learning Theory-Albert Bandura
(1963)
• Albert Bandura was born
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.

Theory
• He suggested that environment causes behavior,
but behavior causes environment also. He called
this concept as reciprocal determinism. The
world and a persons behavior cause each other.
• Development of personality takes place as an
interaction among three things: the environment,
behavior, and the persons psychological
processes. These psychological processes
consist of our ability to entertain images in our
minds, and language.

According to Bandura the steps involved in the modeling

are:
• 1. Attention. If we are going to learn anything, we have
to be pay attention. Likewise, anything that puts a
damper 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, we pay more attention. If the model is
attractive, or prestigious, or appears to be particularly
competent, we will pay more attention. And if the model
seems more like our self, we will pay more attention.

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 have to
have the ability to reproduce the behavior in the first
place.

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.
• Of course, the negative motivations are there as well,
giving us reasons not to imitate someone:
a. past punishment.
b. promised punishment (threats).

• 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.

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

.
• 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.
• 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.

Classical Conditioning Theory-Ivan Pavlov
(1927)
Classical Conditioning.
• 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 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 highly likely that he or
she will 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.

• 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.

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.

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 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.
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.

Operant Conditioning Theory-Skinner
(1938)
• Burrhus Frederic Skinner
was born March 20, 1904,
in Pennsylvania
• He got his masters in
psychology in 1930 and his
doctorate in 1931 from
Harvard, and stayed there to
do research until 1936.

• 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
like to be used again in the future; but if a particular
respond produces an unpleasant consequence, the
probability that response being used in the future is
diminished.

Stimulus

Response

Consequence

• 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 .


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 www.indiandentalacademy.com not desired .
behavior that is

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.

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 tangible reward.

• Adolescents in the orthodontic treatment, for
instance, can obtain reinforcement from a
simple pin saying, ' Worlds greatest
Orthodontic Patient" or something similar. A
reward such as T-shirt with some slogan as a
prize 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.
• 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.

• Concepts of reinforcement as opposed to extinction, and
generalization as opposed to discrimination, apply to
operant conditioning as well as to classical conditioning.
• In operant conditioning, the concepts apply to the situation
in which a response leads to a particular consequence, not to
the conditioned stimulus that directly controls the
conditioned response.
• Positive or negative reinforcement becomes even more
effective if repeated, although it is not necessary to provide
a reward at even 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.

• 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.

CHILD MANAGEMENT


Psychological Management of Orthodontic
Patient : Louis Norton- AO July 1971
•
•
•
•

Young child (6 to 9 yrs)
Easiest to work with.
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 explain 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.

• 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 reenforcement. 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.

• 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.

:

• 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.
• He is also looking for a hero, to emulate. It is not
unusual for a personable dentist to fill this hero's
role for the child.

• 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.

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 either accepted with exuberance or dread.
• 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.
• References to her body, may invite problems.
For example if you say she has got-ten quite tall.
• The conversation should be brief, pleasant,
impersonal and thoughtful.


•
•
•

•

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 a matter of
sympathy and understanding.

• One must be direct and forthright. Being devious or
overly complex will lead to suspicion.
• 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.

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 thrust in management must be toward the
cosmetic and status value.

• Once trust is established, she will usually be
cooperative , probably 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.

• 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 his
parents are concerned about his 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.

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.

The adage "different strokes for different
folks" applies strongly to children, whose
variations in intellectual and psychosocial
development affect the way they receive
orthodontic treatment, just as their differing
stages of physical development do.


REFERENCES
1. Moyers Robert E.: Hand book of Orthodontics.
Year book Medical publishers, Inc, 198; 4th
Edition.
2. Bishara Samir E.: Text book of Orthodontics.
Saunders 2003.456-462.
3. Proffit W R: Contemporary Orthodontics.
Mosby 2000.3rd Edition.48-61.

4. Amanpreet Kaur Grewal, James Sunny P, Valiathan A.
Expectations and perceptions of patients towards
orthodontic treatment in Manipal . J Pierre Fauchard
Academy 2003;19:83-88.
5. Sachdeva Sunil & Valiathan Ashima: "Whose mouth is
it anyway?". Journal of Indian Orthodontic Society,
1994; 22(3): 105-108.
6. Sunil Sachdeva & Valiathan Ashima: Co-operation in
orthodontics. Nepal Dental Journal 1999 :2(1)21-26.
7. Irfan & Valiathan Ashima Dawoodbhoy, : Age &
Orthodontics. Journal of International College of
Dentist. 1993; 34: 20-25

8. Ravinder V.& Ashima Valiathan. Psychology
in Orthodontics. Kerala Dent J,2006; 29(2):
41-43.
9. Louis A. Mark Markowitz. Psychological
management of orthodontic patient: A O.July
1971;41(3):241-248.
10.M M Gershater.The psychologic dimension of
orthodontic diagnosis and treatment
.AJODO,1968;54(5); 327-338.
11.Dale.H.Schunk. Learning theories-An
educational Perspective.2000 ;4th ed. Merrill
Prentice Hall.

12.E.B.Hurlock. Developmental Psychology-A
life span approach .1981;5th ed .Tata
McGraw Hill.
13.John .B. Best. Cognitive psychology ;5th ed .
1998;International Thombson Publishing
Company.
14.Paul Henry Mussen. Child development
and personality; 1984.6th ed ;Harper and row
N.Y.
15.Barbara L. Chadwick .Child taming-how to
manage children in dental practice.
2003;Quintessence Publication.
16.Pinkham .Pediateric Dentistry; 4th ed

17. McDonald. Dentistry for the child and
adolescent .8th ed .2004;Elsevier
18.Jay Weiss. Psychological timing of
orthodontic treatment .AJO 1977:72.2.198203


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