Child psychology /certified fixed orthodontic courses by Indian dental academy

Definition
• Psychology is the science dealing with
human nature, function and phenomenon
of his soul in the main.
• Child psychology is the science that deals
with the mental power (or) an interaction
between the conscious and subconscious
element in a child
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Importance of child psychology
• To understand the child better
• To know the problem of psychological origin
• To deliver dental services in a meaningful and effective
manner
• To establish effective communication with child and the
parent.
• To gain confidence of the child and of the parent
• To teach the child and the parent.
• To have better treatment planning & interaction with
other discipline.
• To produce comfortable environment for the dental team
to work on the patient.

DEVELOPMENTAL TASKS
• BIOLOGICAL:
• COGNITIVE:
• EMOTIONAL:
• SOCIAL:
• Motor function and
adaptation of skills
• Awareness and
intellectual
development
• Personality
development of the
child.
• Social experience ,
morals of society

Theories of child psychology
• Child psychology theories can be broadly classified
into two groups.
(1)Psychodynamic theories
• Psycho sexual theory - Freud(1905)
• Psycho social theory - Eric Erickson(1963)
• Cognitive theory - Piaget(1952)

(2) Behavioral theories
• Hierarchy of needs - Maslow(1954)
• Social Learning Theory - Bandura(1963)
• Classical conditioning - Pavlov(1927)
• Operant conditioning - Skinner(1938)
• Mahler’s theory(1933)

JOHN WEINMAN
• PSYCHOANALYTICAL THEORY
• BEHAVIORAL THEORY
• COGNITIVE THEORY
• BIOLOGICAL THEORY

HOWARD GARDNER
COGNITIVE STRUCTURAL THEORIES
Jean piaget, Laurance Kohlberg,Deanna Kuhn
PERSONALITY OR DYNAMIC PSYCHOLOGY
Sigmond Freud, Eric Erickson, Bruno Bettelheim
BEHAVIOURIST MODELLING THEORIES
B.F.Skinner, Albert Bandura

• ENVIRONMENTAL LEARNING THEORIES
Tracy Kendler, Alexander Luria.
• ORGANISMIC DEVELOPMENTAL THEORIES
Heinz Wernier, Douglass Carmichael.
• ANTHROPOLOGICAL THEORIES
Michel Lole, Margret Mead, John Whiting.

PETER HOARE
• STAGE THEORIES
Piaget
Sigmond Freud
• NON STAGE THEORIES
Learning Theories

Psychosexual theory
• Sigmond Freud (1905)- originator of psychoanalytical approach.
• personality to originate from biological and maturational components
with an invariant sequence of development to everyone
• categorized into 5 psychosexual stages
• At each stage sexual energy is integrated in a particular part called
erogenous zone.
• Two categories in concept of Freudian theory
- level of consciousness (or) awareness
- functional component is personality

There are three levels of consciousness
• Conscious – a part of personality which is aware of
thoughts and feelings for basic activities
• Preconscious – a part of personality of which the
individual is not aware of at the moment however able to
recollect into awareness without great difficulty.
• Unconscious -part of personality of which individual is
unaware, which generally cannot able to bring into
awareness without help of assistant

ID
• Basic structure of personality which serves as the reservoir
of instincts
FEATURES OF ID
Present at birth
Impulse ridden (instinctual)
Strive for immediate pleasure and gratification
Selfish and
Cannot with stand pain
Retention Aggressive Personality

SUPER EGO
• Acts as a censor for acceptability of thoughts,
feelings and behaviour .
• In short, it is the conscious that instructs us on
what to do and not to.
• It is determined by the restrictions imposed by the
parents, society and culture ,i.e. morals and ethics
• It is developed by initial reward and punishment.
• Over punishment leads to decrease in libido and
instinctual development.
• Proper parenting is important.

WEAK SUPER EGO
• Only the Id factor plays, due to no
moral teaching.
This kind of personality can make the
child a criminal at later ages.

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

Functions of ego
• Defense mechanism – prevents the instinctual
impulses from the ID and reduces the level of
anxiety.
• As a positive function in that the individual is able
to avoid crisis.
• As a negative function in that they cause self
deception and prevent the individuals from
accepting the realities of life.
• Composed of escape and compromise techniques

TYPES OF DEFENCE MECHANISM
• PROJECTION: Individual projects ,personal feelings of
inadequacy onto someone in order to feel more comfortable.
• DENIAL: Inability to accept the psychological impact of a
potentially stressful event .
• UNDOING:In an attempt to undo the harm, an individual
imagines what his ID produces.
• IDENTIFICATION: assumption of qualities of some one else
to vent frustration or create fantasy (imitation)

REGRESSION:When an anxiety producing situation comes the
child shows an age in an appropriate response, i.e. behavioural
relapse to a more infantile manner.
REACTION FORMATION:Transfer of hostile or more aggressive
impulses into their opposite or more socially desirable form.
REPRESSION: The process of unconscious forgetting which
allows the suppression, painful experiences into subconscious
mind.

• RATIONALISATION: A strategy developed to
excuse or minimize the psychological
consequences of an event.
• SUBLIMATION: Redirection of socially
unacceptable drives into socially approved
channels to allow the discharge of instinctive
impulses in an acceptable form.
• DISPLACEMENT: The transfer of hostile and
aggressive feelings from a original source to
another, usually a less important one.

STAGES OF DEVELOPMENT
• ORAL STAGE (0 to 1)
• Peri oral region is the area of pleasure
and gratification
• Adequate and regular feeding is very
important.
• A proper balance between too much and
too little or that particular trait will
become fixated at that stage.
• passiveness and dependence.
• Additive behaviour like overeating,
excessive optimism, envy, jealousy
pessimism, demandingness etc
• Satisfaction of this stage helps in the
development of trust and in later years it
result in successful achievements of
needs. www.indiandentalacademy.com

• ANAL STAGE (2-3)
• Anal region- the zone of pleasure.
• Ego centric or self centered behaviour
• Maturation of his neuromuscular
control.
• Child become more independent and
develops personal autonomy.
• Over emphasis of toilet training
causes compulsive ,obstinate ,and
perfectionist behaviour in later life.
• ANAL PERSONALITY: Characterized
by disorderliness abstinence,
stubbornness, willfulness, frugality.
• Less controlled management of toilet
training causes an impulsive
personality

PHALLIC STAGE (3-5yrs)
Child becomes increasingly aware of his
or her genitals, he can differentiate the
sexes.
CHARECTERISTICS
Oedipus complex: boys become
attached to his mother.
Castration anxiety
Resolution of this crisis for boys is to
identify with his father and use him as a
role model.

Electra complex :opposite of
Oedipus complex. Girls get
attached to father
Penis envy: seen in females with
lasting Electra complex
Emergence of super ego or
conscience
Sense of shame and guilt
Emergence of jealous and
competitive feelings towards peers
and siblings
Unsatisfactory resolution leads to
sexual conflicts and inability to
perform sexual relationship, male
and female homosexuality etc

• LATENCY STAGE (5-12yrs)
• Period of consolidation
• More importance is on peer
development and character
formation
• Greater degree of control over
instinctual impulses
• Lack of resolution of this stage can
lead to immature behaviour and
decreased development of skills
• Males tend to act as females and
females tends to act as males
(TOM BOY)

• GENITAL STAGE (12-18yrs)
• Spurt in sexual activity
• Hormonal and physiological
changes increase the interest in sexual
matters
• Most important stage that shapes the
future of a child are oral and phallic
stages.A successful resolution of oral
stages give the foundation of close
trusting relationship while unresolved
phallic stage leads to confusion over
sexual role and behaviour.

COGNITIVE DEVELOPMENT
Jean Piaget 1952
• Survival of the fittest and the most
adaptable is the driving force for
development.
• Cognitive development is the interaction
between the individual and the
environment

FOUR MAJOR ASPECTS OF COGNITIVE
DEVELOPMENT
 Progressive neurological development
 Child has the opportunity to practice newly
acquired skills.
 The opportunity for social interaction
 Internal psychological mechanism or structures
emerge that allows the child to construct
successively more complex cognitive models
based on maturation and experience.

PIAGETS MAJOR CONCEPTS
• Two types of cognitive structure
Schemas and operations
SCHEMAS
Simple mental structure present at birth
Internal representation of some specific
action or behaviour.

OPERATIONSOPERATIONS
Develop later in cognitive development
More complex
Represent internal structures of a high order that
have the distinctive features of being reversible

Adaptation of cognitive structure
By two process
Assimilation: Refers to incorporation of new
objects ,thoughts,and behaviour into existing
structures.
Accommodation: Is the change of existing structures
in response to novel experiences
Equilibration : Is the means by which the individual
balances the competing forces of assimilation and
accommodation.

PIAGETS STAGES OF COGNITIVE
DEVELOPMENT
• Sensorimotor period (birth to 2yrs)
• Preoperational period (2-7yrs)
• Concrete operational (7-12 yrs)
• Formal operational period (>12yrs)

Sensorimotor (0 to 2 years)
• Child born with certain basic characters for interacting with
the environment.
• This primitive strategies mark the beginning of the thinking
process.
• Child does not yet have the capacity to represent object
(or) people to himself mentally.
• As maturation progresses the simple reflexes begin to be
coordinated.
• E.g. arm is moved, eyes keep on watching it
• By l0th month, variety of elementary schemes develop.
• Permanent relating of object develops in course of
coordinating actions with repeated contacts with
environment

Pre-operational stage (2–6 yrs)
• Primitive strategies change in the child.
Assimilates new experiences and
accommodates original strategies.
• The child uses symbols in language with play.
• Learns to classify things.
• solves problems as a result of intuitive thinking
but cannot explain why

Concrete operation stage (6-12 years)
• The thinking process becomes logical
• Ability to use complex mental operations such as
addition and subtraction.
• Child is able to understand others point of view.
• Development based on the level of
understanding achieved so far

Formal operational stage (11-15 yrs)
• Child able to think more abstractly.
• Uses inductive (or) deductive logic to
make decisions to solve problems.
• Thinks of ideas and has developed a vast
imagination.

MERITS AND DEMERITS
Research works have failed to demonstrate the existence of
cognitive structures.
Children are consistently inconsistent in their approach to
problem solving despite using the same cognitive
structures.
Lately it has been suggested that this inadequacy in
problem solving are related to memory power of the child
rather than cognitive ability.

PSYCHOSOCIAL THEORY
ERIC ERICKSON
• Social and cultural dimension to developmental
theory
• Elaborated phase or stage theory covering the
whole life span from birth to death.
• Emphasized the conscious self as much as
unconscious instincts

• In Erickson’s view “Psychosocial development proceeds
by critical steps – ‘critical’ being characteristics of
turning points, moments of decision between
progression, integration and retardation. Each stage
represents a “psychosocial crisis” influenced by social
environment.
• Chronological ages are associated with Erickson’s
developmental stages as in physical development, the
chronological age varies among individuals but
developmental stage remains constant.
• Erickson emphasizes on the conscious self as much as
unconscious instincts.
• Development depends upon child’s instincts and
responses of those around him.
• Unresolved issues from early stages of life affect
persons ability to deal with subsequent stages.

Erickson's eight stages of life cycle
BASIC TRUST VERSUS MISTRUST
AUTONOMY VERSUS SHAME DOUBT
INITIATIVE VERSUS GUILT
INDUSTRY VERSUS INFERIORITY
IDENTITY VERSUS IDENTITY
CONFUSION
INTIMACY VERSUS
ISOLATION
GENERATIVITY
VERSUS
STAGNATION
EGO INTEGRITY VERSUS
DESPAIR

Erickson’s stages of emotional development
Development of Basic trust (Birth to 18 months)
• Initial stage of emotional development a basic trust (or)
lack of trust in the environment is developed.
• Successful development of trust depends on a caring
and consistent mother (or) mother-substitute who
meets both the physiologic and emotional needs of the
infant.
• Bond between child and mother should be maintained
to develop basic trust. If it fails leads to maternal
deprivation.

TASK
Establishment of social relationships
• Good outcome –secure stable relationship
• Bad outcome –insecure ,unsatisfactory
relationships

Development of Autonomy
(18 months-3 years)
• Around the age of 2 yrs children called terrible two’s
because of their un co-operative and obnoxious
behaviour.
• Emotional development moving away from mother by
developing a sense of individual identity (or) autonomy.
• At this stage, wetting one’s pants produces a feeling of
shame.
• Allowing the parent to be present during treatment may
be needed for even the simplest procedure.

TASK
Beginning of independence and of skill
acquisition
• Good outcome-capable and competent
• Bad outcome –dependent and unsure

Development of initiative
(3 to 6 years)
• Continues to develop greater autonomy
• Initiative is shown by physical activity and motion,
extreme curiosity and questioning and aggressive
talking.
• A child is inherently teachable. One part in initiative is the
eager modeling of behaviour of those whom he respects.
• Opposite of initiative is guilt. In Erickson’s view child’s
ultimate ability to initiate new ideas or activities depends
on how he expresses without feeling guilty about
expressing a bad idea or failing to achieve at what was
expected.

TASK
Successful pursuit of certain goals or aims
• Good outcome-confident about skills
• Bad outcome –hesitant ,uncertain

Mastery of skills (Age 7 to 11 years)
• Child works to acquire the academic and social
skills that allow to compete in an environment to
achieve significant recognition.
• In Erickson terms child acquires industriousness
and begins preparation for entering into a
competitive and working world.
• Orthodontic treatment in this age group is likely
to involve in wearing removable appliance.

TASK
Acquisition of scholastic and social skills
• Good outcome-literate, numerate and
socially integrated
• Bad outcome –failure to acquire scholastic
skills ,socially isolated

Development of personal identity
( 12 to 17 yrs)
• Adolescence, a period of intense physical development
and psychosocial development
• A unique personal identity is acquired.
• Extremely complex stage because of many new
opportunities like academic, responsibility and physical
ability changes that arise
• Orthodontic treatment is carried out during adolescence
and behavioral management is challenging as parental
authority is rejected, poor psychological situation if
carried only because parents want them to undergo
treatment.

TASK
Clear sense of own individuality and of aims
in life
• Good outcome-suitable career choice,
satisfactory heterosexual relationship
• Bad outcome –uncertain of career, poor
peer relationship

Development of intimacy
(Young adult 19-25 yrs)
• Develop an intimate relationship with others.
successful development of intimacy depends on
willingness to compromise and even to sacrifice
to maintain a relationship.
• Young adults seek orthodontic care to improve
their appearance as this will facilitate intimate
relationship.
• Factors affecting intimate relationship are
appearance, personality, emotional qualities,
intellect.

TASK
Establishment of satisfactory long term
intimate relationship
• Good outcome-stable relationships and
good career
• Bad outcome –poor intimate relationships
and career choice

Guidance of the next generation (Adult 25-40yrs)
• Major responsibility is establishment and guidance of
next generation as supportive parent.
• Other aspect is service to the group community and
nation.
Attachment of integrity (Late Adult 40+)
• Final stage of psychosocial development with a
combination of gratification with disappointment.
• Feeling of integrity.
• It is a feeling that one has made the best of life’s
situation and peace with it.
• The opposite characteristic is despair.

TASK
Rear children in stable union
• Good outcome-successful career , family
stability
• Bad outcome –poor career attainment , unstable
relationships
Acknowledgement of life’s successes and failures
• Good outcome-acceptance of life’s limitations
and vagaries
• Bad outcome –despondency and despair

MERITS AND DEMERITS
• Compelling and coherent account of development.
Emphasis on the active interaction between the
individual and the environment shaping the final
outcome
• Identity achieved at adolescence as the foundation
for the main tasks, modes and conflicts of the
subsequent life cycle
• A major drawback is the lack of empirical evidence to
support his conclusions.

HIERARCHY OF NEEDS
Abraham Maslow 1954
• A classification of the individuals priority of
needs and motivations during personality
development
• The needs are arranged in a hierarchy and
as one need is satisfied another higher order
need will emerge
• Motivation is constantly required
• Pain avoidance, tension reduction, pleasure
acts as sources of motivation.

• Understanding the totality of the patient
called self actualization
• The ability to use ones capacities to good
purpose to become fully absorbed in what
one seems important, and to do so in a
lively yet selfless manner. He consider a
self actualized individual to be fully
human.

• LEVEL I : PHYSIOLOGICAL
• LEVEL II : SECURITY
• LEVEL III: SOCIAL
• LEVEL IV : ESTEEM
• LEVEL V : SELF ACTUALISATION
LEVELS OF NEEDSLEVELS OF NEEDS

Mahler’s theory (1933)
• This theory categorizes the early childhood
object relations to understand personality
development.
• The period of childhood is classified into three
stages.
-Normal autistic phase
-Normal symbiotic phase.
-Separation individualization phase.

Normal autistic phase (0-1 yr)
• It is a state of half sleep, half-wakefulness
• This phase involves achievement of equilibrium
with the environment.
Normal symbiotic phase (3-4 weeks to 4-5
months)
• Infant at this stage is slightly aware of caretaker
but they both are still undifferentiated.

• Separation individualization process (5-36 months)
• This phase is divided into 4 sub phases.
-Differentiation (5-10 months)
-Practicing period (10-16 months)
-rapprochements (16-24 months)
-Consolidation and object constancy (24-36)
Differentiation (5-10 months)
-Infants are alert as cognitive with neurological
maturation occurs
-Characteristic stranger anxiety present during this
stage.
-differentiates between self and other.

Practicing period (10-16 months)
• Beginning of phase by upright locomotion.
• Child learns to separate himself from mother by crawling.
• Separation anxiety is present, as the child still requires the
mother for safety.
Rapprochement (16-24 months)
• Child becomes toddler aware of physical separateness.
• Childs shows his mother newly acquired skills.
• Mother’s efforts are not helpful resulting in temper
tantrums.
• Rapprochement crisis develops as child wants to be
soothed (calm) by the mother but unable to accept her
help.
• Crisis resolves as the child’s skill improves

Consolidation with Object constancy (24-36
months)
• Child achieves a definite sense of individuality
and is able to cope up with the mother’s
absence.
• Feel comfortable when mother leaves but knows
that she will return
• Develops an improved sense of time and can
tolerate delay.

CLASSICAL CONDITIONING
Ivan Pavlov 1927
Based on stimulus reflex response ( an involuntary
response to an external stimuli)
When two events ,observed to occur together
(proximity in time and space),will tend to be
associated or paired together by the
observer(pairing of initial and neutral stimuli).

The principles involved in these process are
Generalization
• Process of conditioning is evoked by a band of stimuli centered
around a specific conditioned stimulus. Thus a test stimulus similar
to training stimulus results in response.
Extinction
• If reinforcement does not occur results in extinction of the fear.
Discrimination
• It is opposite of generalization. If the child is exposed to clinical
setting which are different, child learns to discriminate between the
two clinics and even the generalized response to any office will
extinguish.

PRINCIPLES
• Developing good habits.
• Breaking habits and elimination of
condition fear
• Psychotherapy, to decondition emotional
fear
• Developing positive attitudes
• Teaching alphabets.

OPERANT CONDITIONING
1. Positive reinforcement
• Occurs if a pleasant consequence follows the response e.g., a
child rewarded for good behaviour following dental treatment.
2.Negative reinforcement
• Involves removal of unpleasant stimulus following a response, e.g.,
if the parent gives into the temper tantrums thrown by the child, he
reinforces this behaviour.
3.Omission
• Refer to removal of the pleasant response after a particular
response e.g., if the child misbehaves during dental procedure. If it’s
favorite toy is taken away for short time resulting in the omission of
the undesirable behaviour.
4.Punishment
• Involves introduction of an aversive stimulus into a situation to
decrease the undesirable behaviour, e.g., use of parental rake in
correction of tongue thrusting habit.

Social learning theory
Bandura (1963) proposed social learning
theory . Thought to be the most complete.
Clinically useful and theoretically a sophisticated
form of behaviour therapy.
Advantages
• Less reductionistic
• Provides more explanatory concepts.
• Encompasses a broader range of phenomena.

• The learning behaviour affected by 4 principle elements.
Antecedent determinants
The conditioning is affected if the person is aware of what is
occurring.
Consequent determinants.
Person’s perception and expectancy (cognitive factors) determine
behaviour.
Modelling
Learning through observation eliminates the trial – error search. It is
not an automatic process but requires cognitive factors and involves 4
processes which are
• Attentional Processes
• Retention processes
• Reproduction processes
• Motivational processes
Self – regulation
This system involves a process of self-regulation judgment and
evaluation of individual’s responses to his own behaviour.

Oral theory of sears with wise (1950)
• According to this theory strength of oral
drive is in part of function of how long a
child continues to feed by sucking. Thus it
is not frustration of weaning that produce
thumb sucking, but oral drive, which has
been strengthened by the prolongation of
nursing.

Benjamin theory (1960)
• He says, “Thumb sucking arises from
the rooting (or) placing reflex seen in all
mammalian infants. Rooting reflex is the
movement of the infant’s head and tongue
towards an object touching his cheek.
The object is usually the mother’s breast
but may also be a finger (or) a pacifier.
This rooting reflex disappears in normal
infants around 7-8 months

Dunlop Beta hypothesis
• He states that best way to break a
habit is by its conscious, purposeful
repetition. He suggests that the child
should be asked to suck his thumb
observing himself as he indulges in the
habit.
• This procedure is very effective if the
child is asked to do the same at a time
when he is involved in an enjoyable
activity.

BEHAVIOUR MANAGEMENT

Factors influencing behaviour
• Growth and development
• Family and peer influences
• Past dental and medical experiences
• Dental office environment

Factors which affect child's behaviour in the
dental office :
• Under the control of the dentist
• Out of control of the dentist
• Under the control of the parents

Under the Control of the Dentist
1.Dental Clinic :
• Dental office should be warm and simulate a homely environment.
Healthy communication should be established.
• A pleasant environment helps to relieve the child’s anxiety about the
dental situation.
• The operating environment should be made colorful and lively with
posters, TV and videogames and separate waiting room for
children.
• It should have a separate exit and an entry door.
• Appointment time should be kept short. Early morning appointments
are preferable for children. Children should not be kept waiting for
too long as they tend to become restless.

2.Effect of dentist’s activity and attitude
• The dentist should form a good
impression on the child.
• Should avoid jerky and quick movements
• Should be fluent in his words and actions

Jenks in 1964 described six categories of activities by
which the dentist can fasten or enhance co-operation in
children.
They are
Data gathering and observation
• This involves collecting the type of information about a
child and his parents that are obtained by a formal or
informal office interview or by written questionnaire.
• Observation includes noting behaviour of the child as he
steps into the dental office during history taking and
while the dental procedure is being carried out.

Structuring
• Refers to establishing certain guidelines of behaviour set by the
dentist and his team to the child. So that the child knows what to
except and how to react. He also prepares the child for each phase
of the treatment in advance.
Externalization
• It is a process by which the child’s attention is focused away from
the sensation associated with the dental treatment.
Components of externalization
--- distraction
--- involvement
• The objective is to interest and involve the child but at the same
time not to let him into verbal or motor discharges which might
interfere with the necessary procedure.

Empathy and support:
• Empathy is the capacity to understand and to experience
the feelings of another without losing ones own
objectivity. The dentist should have empathy to the
child’s feelings.
This can be achieved by
• Permitting the child to express their feelings without
rejection and listening when they wish to talk.
• Communicating to the child so that their feelings are
understood.
• Comforting the child when needed
• Encouraging children when they show acceptable
behaviour.

Flexible authority
• Includes compromises made by the dentist to
meet the needs of the particular patient.
Education and training
• A program that educates both parents and
children should be implemented on what
constitutes good health and which stimulates
them to make behavioral changes necessary to
achieve these goals.

3. Effect of dentists attire
• The previous stressful experience of the child, the dentist
white attire. The mere presence of the white attire would
evoke a negative behaviour.
4.Presence or absence of parents in the operatory
• Mother’s presence is essential for a pre schoolchild,
handicapped child etc. An older child does not require
mother’s presence because of the emotional
independence of these children.

5.Presence of older sibling
• Older sibling serves as a role model in a dental
situation. This again depends on the age of the
patient. A presence of an older sibling has
• little effect on behaviour of a 3 year old patient
• no effect in case of 5 year olds
• most noticeable effect in case of 4 year olds

II. Out Of Control Of The Dentist
1. Growth and Development
• Deficiency in physical growth, congenital malformation.
As awareness of the deficiency increases it leads to
psychological trauma due to the rejection by the
society.
• Mentally handicapped children who cannot react to the
requirements and therefore variations in behaviour are
encountered.
• A very young child shows negative behaviour and the
same response may be transformed to a positive
behaviour, as the child grows older.

2. Nutritional Factors
• Intake of sugar causes irritable behaviour
• Hypoglycemia causes criminal behaviour
• Skipping breakfast leads to impaired performance
• Nutritional deficiency affects the milestones of biological
and cognitive development.
3. Past medical and dental experiences
• Any past unpleasant dental experience is associated
with high degree of uncooperative behaviour. Emotional
quality of the past plays a near significant role than the
number of visits.

4. Genetics
• Genetic influence is modified by the environment i.e. there should
be a constant interaction between genetic programme of the child
and environment for the psychological development of the child.
5. School environment
• 50% of child’s development is affected by the school. The teacher &
peers help to influence the behaviour of younger children and
seniors become role models to juniors.
6. Socio-economics status
• The higher group develop mostly normally as all necessary
requirements are met adequately and they aid is normal psychologic
development. On the other hand, they may become spoilt if they get
everything they demand.

III. Under the control of the
parents
1. Home environment
• Home is the first school for the child.
• The first place where the child learns how to behave. All
the individuals at home influence the child’s behaviour
but none so much as the mother. The mother child
relationship has been described as one tailed.
E.g. in case of a broken home the child may feel insecure,
inferior and depressed.
• Post natal behaviour of the child depends on the
prenatal emotional status of the mother.

2. Family development and peer influence
• The position of the child, status of the child in the family
& parental attitudes influence the child’s behaviour. Over
indulgence can lead to exploit behaviour in the child who
may show sudden out bursts and temper tantrums.
• Internal family conflicts affect the behaviour as the child
can sense disharmony and this can emotionally frustrate
the child.
• Sibling relationship influences the Childs behaviour. The
younger child tries to follow the model of the older sibling
and family member thus showing the same behaviour of
sibling.

3. Maternal Behaviour
• Prenatal characteristics are unilateral & termed one
tailed
• Maternal influence on the children’s mental, physical and
emotional development begins even before birth.
• Somatic development of fetus depends on nutritional
status of the mother.
• Neurohormonal system of mother transfers emotion to
the factors.
• Postnatal behaviour of the child is linked to pre natal
emotional status of the expectant mother.
• Emotional stress during pregnancy can lead to an
excessively active and irritable infant
• Alcohol, smoking, keratogenic drugs affect the child’s
development if consumed during pregnancy.

4.Maternal influences on personality development
• The mother–child relationship falls into two categories
Autonomy VS Control
Hostility Vs Love
• Mothers who allowed enough autonomy & who expressed affection
had children who were friendly & cooperative. Punitive mothers and
those who ignored their children exhibited negative behaviour.
5. Maternal attitude & Childs behaviour
• Over protective – shy, submissive, anxious
• Overindulgent – Aggressive, demanding, temper tantrums
• Under affectionate – usually well behaved, but unable to cooperate,
shy & may cry easily.
• Rejecting – Aggressive, overactive, disobedient
• Authoritarian - Evasive & dawdling

Behaviour shaping:
• Is the procedure, which slowly develops
behaviour by reinforcing a successive
approximation of the desired behaviour
until the desired behaviour comes into
being.

BEHAVIOUR MODIFICATION
Defined as an attempt to alter human behaviour and emotion in a
beneficial way in accordance with the laws of learning.
Behaviour management classified as
NON Pharmacological Pharmacological
• Communication pre medication
• Behaviour modification sedatives and hypnotics
Desensitization anti anxiety drugs
Modelling anti histamines
Contingency conscious sedation
Behaviour management general anesthesia

Communicative Management.
• Used in both cooperative and uncooperative child
(Chambers in 1976).
• This is the basis for establishing a relationship with the
child which allows successful completion of dental
procedure and at the same time help the child develop
positive attitudes towards dental care.
• Means by which the dentist gets his point across by
making himself understood by the use of expressions.
• The communication should always be established from
the first entry.
• i.e. to the reception area.

• Type of communication:
Verbal -> by speech
Non-verbal -> (multi sensory communication)
Both -body language
Smiling
Eye contact
Showing concern
By touching the child
Giving him a pat
Giving him a hug
Expressing without speaking.

To Communicate ways:
• Communication should be relaxed & comfortable
• language that is chosen should contain words that express pleasantness,
friendship and concern.
– Verbal communication is best for children more than 3yrs of age. Voice
that is used should be constant and gentle. Tone of voice can express
empathy & firmness & support.
– Content of the conversation should make the child feel that the dentist is
his well-wisher. Conversation should include asking the child’s name,
age, class and background.
– Always the patient should be addressed by name.
– Communication should be from a single source either between the
dentist and the child or the child & dental assistant to avoid confusion.
The child is very sensitive to expression changes
– sitting and speaking at the eye level allows for a friendlier atmosphere.
• - Communication is a multisensory process in the sense that it
includes a transmitter, the spoken word is the medium and the pediatric
patient is the receiver.
• - Use of euphemism/substitute words can influence the
behaviour.
E.g. Anesthetic sol is referred to as water to put teeth to sleep
,radiograph as tooth picture.

Behaviour Shaping :
Modification
Involves three techniques
• Desensitization
• Modeling
• Contingency management
Desensitization :
• Joseph wolpe in 1975 used this techniques to remove
fears and tension in children who have had previous
unpleasant experience.
• It is accompanied by teaching the child a competing
response such as relaxing and then introducing a
threatening stimuli

Tell show do(TSD) Technique
• Addleston in 1959 introduced the concept of TSD.
• Tell & show every instrument & step and explain what is going to be done.
• Continuously and in grades the procedure should be moved from the least
fear promoting object to more fearful ones.
• Indication for TSD:
– 1st visit.
– Subsequent visits when introducing new procedure
– Fearful child.
– Apprehensive child because of information received by peers or parents.
• TSD techniques are applied as follows:
• Explaining the procedure slowly and repeatedly by using the language or
terms that the child can understand. The dentist demonstrates the
procedure exactly as explained.

MODELLING
• Bandura in 1969 introduced & develop from social
learning principle procedure that allows a patient to
observe one or more individuals (models) who
demonstrate a +ve behaviour in a particular in situation.
Therefore, the patient will frequently imitate the model’s
behaviour when placed in a similar situation.
Modelling can be done by
• Live models – siblings, parents of child etc.,
• Filmed models
• Posters
• Audio - visual aids.

• Learning through modeling is effective when
– observer is in a state of arousal
– model has relatively more status and prestige
– +ve consequences associated with models behaviour
– ( improves the behaviour of apprehensive children
who have had no past dental experiences. Klarman R
1980)
• ADV: No additional equipment, personal or
alterations in the dental routine are required.

CONTINGENCY
MANAGEMENT
Method of modifying the behaviour by presentation or
withdrawal of reinforcers.
• A +ve reinforcers: Henry W Fields in 1984. In this the
contingent presentation increases the frequency of
behaviour.
• B –ve rein forcers: Stokes and Kennedy in 1980. In this,
the contingent withdrawal increases the frequency of
behaviour this is generally a termination of an aversive
stimulus.
• E.g. withdrawal of the mother.

• Types of reinforces can be:
1 social: eg praise, +ve facial expression, physical contact
by shaking hand, holding & patting shoulder on the back
2 material: may be in the form of toys, games.
3. Activity reinforcers : involving the child in some activity
like watching a T.V show /special programmer
• For the contingency management social reinforces are
the most effective.

Behaviour Management
Audio analgesia: or “white noise” is a method of
reducing pain.
• This technique consists of providing a sound
stimulus of such intensity that the patient finds it
difficult to attend to anything else
( Gardner,licklider,1959). Auditory stimulus such
as pleasant music has been to reduce stress
and also reduce the reaction to pain.

2. BioFeedback: (Buonomono 1979)
• Involves the use of certain instruments
to detect certain physiological processes
associated with fear.
• E.g. If B.P. is high, the instrument gives
stimulation and subject is taught to control
the signals, therefore it is useful in anxiety
and stress related disorder.

3. Humor :
• Helps to elevate the mood of the child and this helps
the child to relax
Functions of humor.
• Social : forming and maintaining relationship
• Emotional: Anxiety relief in the child.
• Information : Transmission of essential information in a
non threatening way.
• Motivation: increases the interest and involvement of the
child.
• Cognitive: Distraction from fearful stimuli.

4. Coping:
• The mechanism by which the child copes up with the
dental treatment.
• Lazaue in 1980 defined coping as the cognitive and
behavioural effects made by an individual to master,
tolerate or reduce stressful situation.
• Pts under stress prefer to draw comfort or
reassurance from an authority figure, thus establishing a
close or trusting relationship with the dentist or dental
assistant.
2 types of coping effects
a .Behavioral:
• Are the physical and verbal activities in which the child
engages to overcome a stressful situation.

b. Cognitive
• Child may be silent and thinking in his mind to keep
calm. It enables the children to maintain realistic
perspective on the events at hand (reality oriented
working)
• Perceive the situation as less threatening (cognitive re
appraisal).
• calms and reassures themselves that everything will be
all right (emotion regulating cognition) [Sandra L Curry
1988].
Signal system
• Is a method of coping suggested by Musslemann in
1991, the child is asked to raise his hand when it hurts.
The normal coping system followed by the dentists to
reduce tension & pain are friendliness, support &
reassurance

5 Voice control
• It is the modification of intensity and pitch of one’s own
voice in an attempt to dominate the interaction between
the dentist and the child.
• used in conjunction with some form of physical restraints
and hand over mouth exercise change in tone from
gentle to firm is effective in gaining the child’s attention
and reminding him that the dentist is an authority figure
to be obeyed.
6 Relaxation
• Used to reduce stress and is based on the principle of
elimination of anxiety.

7 Hypnosis
• Hypnosis is an altered state of consciousness
characterized by a heightened suggestibility to produce
desirable behavioral & physiological changes.
• Romanson in1981 : One of the most effective non
pharmacologic therapies used in children for a no. of
different procedures.
• Richardson in 1980 : when used in dentistry-
hypnodontics or psychosomatic or suggestion therapy.
8 Implosion therapy
• Mainly comprises of home, voice control & physical
restraints

9 Aversive Conditioning:
• Safe & effective method of managing extremely negative
behaviour.
Common method - HOME
-PHYSICALRESTRAINTS
• Before using these techniques dentists should obtain
prior permission from the parents
( Patricia Hagan 1984)

Home (Hand over mouth exercise)
Introduced by Evangeline Jordan in 1920
Purpose: to gain attention of the child so that communication can be achieved.
Indication:
• A healthy child who exhibits defiance and hysterical behaviour during
treatment.
• 3 to 6 yrs old
• Children displaying uncontrollable behaviour.
Contra indications:
• Child under 3 yrs of age.
• Handicapped child immature /frightened children (physical, emotional,
mental).

Several variations of home:
• Hand over mouth with airway restricted &
nose.
• Towel held over the mouth only.
• Dry towel held over the nose & mouth.
• Wet towel held over the nose & mouth.

Homar (airway restricted):
• Adv: child will be quiet so as to breathe
and the screaming will decrease as that
the doctor can proceed.
• Together with hand over mouth the
nostrils are pinched for 15 secs.
• Belanger in 1993 as airway restriction was
the critical element it should be avoided.

Physical Restraints
• Last resort for handling uncooperative/handicapped patients
• Kelly in 1976 suggested that restraints are generally needed for
children who are hyper motive, stubborn or defiant.
• The child is seated in the mother’s lap and one of the mother’s hand
is placed on the child’s forehead while the other hand is placed on
both the child’s wrists.
• Physical restraints involve restriction of movement of the child’s
head, hands, feet or body.
It can be
1 active – restraints performed by the dentist or the dental assistant
without a restraining device.
2 passive – with the aid of restraining device.

Type of restraints:
• For the body – Pedi wrap, papoose board, sheets, bean bag with
strap, towel and tapes.
• For extremities – Velcro straps, posey straps, towel& tape.
• For the head - Head positioner, fore arm body support.
• For the mouth – mouth blocks, banded tongue blades.
Mouth props: They are used at the time of L A to prevent child from
closing his mouth. Also used for handicapped child.
• Child who cannot keep the mouth open for a long time.
• Child becoming extremely fatigued due to long appointment

Relating emotional maturation to
the dental situation
Two years old:
• This age also referred as the terrible two. At 2 yrs of age their ability
to communicate is very less as vocabulary at that age range from 12
to 1000 words only. The 2 yr child is often referred to as being in
the pre-cooperative stage. Solitary play is preferred as the child has
not learned to play with other children . The child is too young to be
reached with words alone & must handle & touch objects slowly in
order to grasp their meaning fully.
• The young child fears falling or sudden unexpected movements.
Suddenly being lowered or tilted back in the dental chair without
warning can cause fear. Quick jerky movements of the hands are
frightening. Separating the young child from the parent is extremely
difficult & the 2 yrs old should be accompanied by parent to the
treatment room.

Three years old:
• It is easier & 3 yr olds communicate better with the
dentists. They have a great desire to talk and often enjoy
telling stories to the dentist. At this stage the dental
personnel makes a positive approach with the child. It is
better to speak positively to this child, as they are apt. to
do things they are asked not to.
Four Year Old:
• The 4 yrs old usually listens with interest to explanations
and is normally responsive to verbal directions. He is
generally a good dental patient. In some situations, they
become defiant. Fear of strangers is lessened by the age
of four-.the prick of hypoderm or sight of blood following
tooth extraction may produce a reaction disproportionate
to the degree of pain.

Five Year Old:
• The 5 yr old has reached an age of readiness to accepts group
activities and community experiences. A 5 yr old properly prepared
by the parents has little fear of being separated from the parents for
the dental appointment. The children in this age group are usually
proud of their possessions and to establish a good rapport. A +ve
appreciative comment about clothes is an effective method.
Six to twelve Years old:
• In the period from 6 to 12 yrs of age the child learns about the
outside world & become increasingly independent of the parents.
These are years when closely, knit group are formed and they are
important years to teach how to get along with people and abide by
the rules of the society
• The child at this age can generally resolve fears of the dental
procedures because the dentist can use reason and explain what is
being done. The child also has learned to tolerate unpleasant
situations and hand marked desires to be obedient, carrying
frustrations well.

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