Child psychology

Child Psychology is important for the development of child behaviour

#childpsychology #childbehaviour #behaviouralpedodontics #theoriesofchildpsychology #behaviourmanagement #behaviourofchildindentalclinic #freudspsychodynamictheory
#conscioussedation #modelling #behaviouralmodelling

1. Behaviour of Child in Dental Office Danish Hamid Final prof Roll no 02

2. Contents Introduction Theories of child psychology Classification of child behaviour Behaviour management

3. Human personality is defined by the pattern of thought, emotion and behaviour which influences his/her interaction with environment Behaviour includes observable and potentially measurable activities which can be described in similar ways by one or more persons Behaviour of child is defined as the pattern in which responds to any social and environmental stimulus Behavioural pedodontics is the study of science which helps to understand development of fear, anxiety and anger as it applies to child in dental situation

4. Theories of Child Psychology PSYCHODYNAMIC/PSYCHOANALYTICAL THEORIES Psychosexual theory Psychosocial theory Cognitive theory THEORIES OF LEARNING AND DEVELOPMENT OF BEHAVIOUR Classical conditioning Operant conditioning Hierarchy of needs Social learning theory Radical Behaviourism by Watson (1913)

5. PSYCHOSEXUAL THEORY It was given by Sigmund Freud in 1905 It is also known as Classical Psychoanalytical theory He emphasised on biological and sexual determinants of development He described human mind by two models Topographic model Psychic model

6. Topographic model Freud compared human mind to an iceberg Conscious mind Preconscious mind Unconscious mind Unsatisfied drives and unconscious wishes cause all psychological events

7. PSYCHIC MODEL Personality is composed of three major systems The ID The EGO The SUPEREGO Each system has its own functions but interact to govern behaviour

8. ID Most primitive and instinctive part of personality Impulse gratification immediately Obeys Pleasure principle i.e endeavours to obtain pleasure (if it feels good, do it) Id is unconscious part of our psyche which responds directly and immediately to basic urges, needs, and desires Id isn’t affected by reality! logic or everyday world Id engages primary process thinking, which is primitive, illogical, irrational and fantasy oriented

9. EGO Ego is that part of id which has been modified by direct influence of external world It is the only part of conscious personality Understands Impulses can’t be gratified immediately, often compromising or postponing satisfaction Obeys realistic principle and works by reason Ego also seeks pleasure but by devising a realistic strategy Child reflects ability to perceive, learn, remember, and reason

10. SUPEREGO Internalized representation of the values and morals of society as taught by parents & other It is a part of unconscious that is the voice of conscious (doing what is right) and source of self-criticism Strives for perfection They are aware of their own transgressions and will feel guilty or ashamed of their unacceptable conduct

11. ID Allows child to obtain food instantly in whatever mode
There is no waiting period EGO Ego instructs child to resist taking food till a more realistic or a practically acceptable situation arises SUPER EGO It directs child to wait till lunch hour since it isn’t right to have it now If Child is hungry

12. Ego defence mechanisms Violating the superego’s standards or even the impulse to do, produces anxiety There are many strategies to reduce anxiety known as Ego’s mechanism of defence. Examples: Denial, Displacement, Projection, Reaction formation, Regression, Repression, Rationalization, Identification.

13. Developmental stages by Freud Oral stage Age : 0 - 1 yr Characterized by passiveness and dependency Primary zone of pleasure is Oral region If gratification not received, fixation occurs for example; Digit sucking habit Anal stage Age : 1 - 3 yrs Marked by Egocentric behaviour Primary zone of pleasure is Anal region Gratification by expelling or withholding feces Toilet training; Good : compulsive, obstinate and perfectionist behaviour Not good : impulsive personality

14. 3. Phallic stage Age : 3 - 6 yr Sex identification is an important feature of this stage Child begins to have sexual impulses towards parent of opposite sex It is called Oedipus complex in boys and Electra complex in girls In phobic child, unconscious, unacceptable wishes and feelings are transformed into fears 4. Latency stage Age : 6 - 12 yrs Period of consolidation Repression of sexual urges and deviation into other activities Skill development for coping up with environment

15. 5. Genital stage Age : Puberty Struggle to gain mastery and control over impulses of id and superego Mood swings and preoccupation with thoughts d/t struggle to attain a firm sense of self

16. PSYCHOSOCIAL THEORY It was given by Erik Erikson in 1963 It is also called Developmental tasks theory since developmental tasks or crisis need to be resolved in order to continue healthy pattern of growth He emphasized on child rearing experiences, social relationships and cultural influences He stressed children are active, curious explorers who seek to adapt to their enivornments

17. Stage I : TRUST VS MISTRUST ( 0-1 yr) The primary caregiver is key social agent Infant develops trust when their world is consistent and predictable i.e. fed, warmed and comforted well If caregiver is rejecting and inconsistent infant develops mistrust Corresponds to Oral stage of Freud Dental application: Child identifies separation anxiety Treatment is to be done with parent present and holding child

18. Stage II : AUTONOMY VS SHAME (1 - 3 yrs) Parent is the key social agent Child begins to assert independence Child should be given a sense of autonomy to dress, feed or look after themselves If failed to achieve this independence, child develops doubt and feels ashamed Dental application Parents presence is essential in dental clinic Dentist must obtain cooperation by making child believe treatment is their own choice

19. Stage III : INITIATIVE VS GUILT (3 - 6 yrs) The family is the key social agent Child begins to be task oriented and plans new activities Child attempts to act grown up and tries to accept responsibilities If activities or goals conflict, child develops guilt Dental application Visit to be view as new adventure If visit fails, it leads to sense of guilt in child Child can be taught about various things in dental setup

20. Stage IV : INDUSTRY VS INFERIORITY (6-12 yrs) Teachers and peers are social agents Child begins to perform tasks and masters social and academic skills Achievements and sense of confidence makes child feel self-assured Failures and lack of confidence makes child to have strong feeling of inferiority Dental application Utilizing sense of industry, we can obtain co-operation of child Co-operation depends on whether peer group is supportive

21. Stage V : IDENTITY VS ROLE CONFUSION (12-18 yrs) Society of peers is key social agent This is cross road between childhood and society Major conflict at this stage is one’s role and identity in the society ( who am I) Failure to solve this conflict results in role confusion and diffusion in society Dental application Any orthodontic treatment at this stage should be carried out if the child wants it, not parents Approval of peer group is important

22. Stage VI : INTIMACY VS ISOLATION (18-25 yrs) Lovers, spouses and close friends are key social agents Primary task is to form strong friendships and to achieve sense of love and companionship with another person If the person is unable to form friendships or intimate relationship, he develops feelings of loneliness and isolation Dental application External appearances are very important Young adults seek orthodontic treatment to correct dental appearance Treatment must be fully explained and discussed with the young adult

23. Stage VII : GENERATIVITY VS STAGNATION (25 - 40 yrs) Spouse, children and cultural norms are main social agents Tasks are becoming productive in work and raising families or looking after needs of young people If unable or unwilling to do these tasks makes the individual to become stagnant and self-centered

24. Stage VIII : INTEGRITY VS DESPAIR (40 - 65 yrs) Life experience is the social agent Older adult looks back at his life, viewing it as either a meaningful, productive and happy experience or a disappointed life full of unfulfilled promises and unrealistic goals

25. COGNITIVE THEORY It was given by Jean Piaget in 1952 The term ‘cognitive’ refers to elements of perception, awareness, judgment and ability to comprehend empirical knowledge Central concept of theory is the operation or the operational structure Operation is the manipulation of ideas that can be reversed allowing the person to return mentally to beginning of the thought sequence The growth in cognitive structures takes place as; Assimilation, Accommodation and Equilibration

26. The process of assimilation, accommodation and equilibration function throughout life as one adapts his behaviour and ideas to changing circumstances Assimilation is seen when a 5 yr old girl learns that objects that fly in the sky are called birds. But when she sees a helicopter and tries to assimilate it to bird, the noise, size and shape of helicopter doesn’t fit to it. She realizes that she needs a new category for it. Parents might help her with new word ‘helicopter’ and explain difference between two. This is Accommodation i.e. tendency to change in response to environmental demands. As a result of this new knowledge the child is in a stage of Equilibrium or Cognitive harmony. The process of establishing equilibrium is called Equilibration.

27. Sequence of Development Sensorimotor stage (0-18 months) Intelligence is manifested in action It starts with automatic inborn reflexes and then co-ordination of these reflexes improves By end of this stage, child will have transformed into organism totally dependent on reflex and other hereditary equipment to a person capable of symbolic thought Dental application: Child begins to interact with the environment and can be given toys while sitting on dental chair

28. Pre-operational stage (2 - 7 yrs) Essential characteristic of this stage is imitation Child uses symbols to represent things They become imaginative in play activities Dental application: Child likes to explore things and make observations. They begin to correlate things like explains radiographs as tooth picture

29. Concrete operational stage (7 - 12 yrs) Child is able to reason logically and quantitative They are able to focus their attention on things and understand the relations between dimensions Child is able to arrange this according to size or weight Dental application : Allowed to hold mouth mirror or suction tube Given concrete instructions

30. Formal operational stage (12 yrs onwards) Development of reasoning Uses wide variety of strategies in problem solving Thinks about future Sees things from a number of perspectives Dental application: Orthodontic appliances can be given Acceptance from peers can be used as motivation

31. Behaviour Learning Theories Learning is a relatively permanent change in an organism’s behaviour as a result of experience

32. CLASSICAL CONDITIONING THEORY by Pavlov (1927) Conditioning means presenting neutral and unconditioned stimulus at the same time repetitively to produce conditioned stimulus The theory is based on experiment on dog Behaviour was studied i.r.t. various internal and external stimuli It is based on involuntary reflexive behaviour

33. Dental application

34. Principles involved in classical conditioning Acquisition: learning a new response from environment by conditioning Generalisation: process of conditioning is evoked by band of stimuli centered around a specific conditioned stimulus Extinction: the association between conditioned and unconditioned stimulus becomes less strong because of lack of reinforcement, ultimately the response vanishes Discrimination: exposure of child to a different clinical setting wherein painful response is not present, the child learns to differentiate between the two

35. OPERANT CONDITIONING THEORY by Skinner (1938) Experimental animal was Rat Behaviour patterns were studied i.r.t. numerous rewards and outcomes It involves voluntary behaviour outcomes Behaviours that operate or control the environment are called “ operants ” The relationship between the operants or behaviours and the consequences that follow them is called “ contingency ”

36. Positive reinforcement Negative reinforcement Punishment Omission / Response cost / Time out Contingency arrangements in operant conditioning

37. Positive reinforcement: When a behaviour f.b. a rewarding event. It strengthens the desired behaviour by using consequences that are pleasant when they happen. Negative reinforcement: When a behaviour is f.b. termination of aversive event thus increasing likelihood of the behaviour. Punishment: When a behaviour is f.b. onset of aversive event. It decreases the frequency of a behaviour by using consequences that are unpleasant when they happen. Omission: When a behaviour is f.b. termination of positive event. The probability of misbehaviour is decreased

38. SOCIAL LEARNING THEORY by Albert Bandura (1963) Behaviour is motivated by our social needs Reinforcements serve regulating behaviour but inefficient for learning behaviour Humans are active information processors It is based on Bobo doll experiment Main components of theory are modelling and vicarious reinforcement

39. Modelling is imitation of behaviour learned from environment through process of observational learning Individual needs to pay Attention to the behaviour Individual must be willing to learn the behaviour; Motivation Individual must be able to replicate the behaviour; Reproduction Individual must remember the behaviour; Retention

40. Vicarious reinforcement results in change of response consequences of the model For example; anxious dental patients observing other patients undergoing dental treatment without unpleasant consequences will tend to lose their fears of dentistry. How to do modelling in dental clinic? Live models Verbal instruction model Symbolic model

41. HIERARCHY OF NEEDS by Abraham Maslow (1943] There are five different levels of Maslow’s hierarchy of needs The theory suggested that people are motivated to fulfill basic meeds before moving on to other, more advanced needs Maslow’s hierarchy is most often displayed as a pyramid Needs are powerful motivators of human behaviour since their fulfillment is strongly correlated with happiness

42. Classification of child behaviour in dental office FRANKL’S CLASSIFICATION (1962) Definitely negative Refuses treatment
Cries forcefully
Extreme negative behaviour associated with fear Negative Reluctant to accept treatment
Displays evidence of slight negativism Positive Accepts treatment and displays tense cooperative, whining or timid behaviour Definitely positive Looks forward to and understands the importance of good preventive care and establishes a good rapport

43. Wright’s classification (1975)

44. Behaviour Management The means by which the dental health team effectively and efficiently performs treatment for a child and, at the same time, instills a positive dental attitude Wright (1975) Behaviour management is a comprehensive methodology meant to build a relationship between the patient and the dental professional which ultimately builds trust and relieves fear and anxiety

45. Behaviour management techniques Psychological approach Pre-appointment behaviour modification Communication Use of second language (Euphemism) Tell-Show-Do Tender love care Desensitisation Contingency management Visual imagery Modelling Behaviour shaping Assimilation and coping Hypnosis Restraining Distraction Externalization Parental presence or absence Reframing Voice control

46. Physical approach Hand over mouth Physical restraints Pharmacological approach Premeditation Conscious sedation General anaesthesia

47. Pre-appointment behaviour modification Audiovisual modelling Goal is to reproduce the behaviour exhibited by model Child sees video before appointment Facilitation of appropriate behaviour and eliminate inappropriate behaviour Pre-appointment mailing It serves in establishing good relationship It prepares patient for first dental visit and increases likelihood of success

48. Communication By involving the child in conversation, the dentist not only learns about the patient but may also relax him Ways of communication : Verbal & Non-verbal Verbal communication includes use of words in positive, understandable and honest way Non-verbal communication is the reinforcement and guidance of behaviour through appropriate contacts, posture, facial expression and body language

49. Use of second language (Euphemisms) Different words are used used for dental instruments and materials such that substituted words are inoffensive, pleasing and meaningful for child Anaesthetic —————> Sleepy water Caries —————> Sugar bug Rubber dam —————> Raincoat X-ray —————> Camera Radiograph —————> Picture Stainless steel band —————> Ring for the tooth

50. Tell-Show-Do It was introduced by Addleston in 1959 It is a behaviour modification procedure to introduce children to dental equipments and procedures TELL : verbal explanation of procedures in phases appropriate to the developmental level of the patient SHOW : demonstration of the visual, auditory, olfactory and tactile aspects of procedure in a carefully defined, non-threatening setting DO : without deviating from the explanation and demonstration, the dentist proceeds directly to perform the previewed operation Modifications: Ask-Tell-Ask & Tell-Play-Do

51. Desensitization Demonstrated by James and popularized by Wolpe It means to take away ones sensitivity to a type of behaviour Used for children having pre-established fears and uncooperative behaviour It pairs an anxiety-evoking stimulus with a response inhibitory to anxiety. The perceived link between stimulus and anxiety is weakened A graded introduction of the child to dentistry, TSD approach and accomplishment of easy procedures like examination, prophylaxis, fluoride treatment and brushing instructions are aspects of desensitisation

52. Modelling It is based on Bandura’s social learning theory It states that one’s learning or behaviour acquisition occurs through observation of suitable model performing a specific behaviour It allows to eliminate or minimize fear of dentistry in children It is useful in children of age 4-5 yrs Types of Modelling; Audiovisual Live modelling by siblings or parent

53. Behaviour shaping It is defined as a process which slowly develops a behaviour by reinforcing successive approximations of the desired behaviour until the desired behaviour is expressed The dentist teaches a child how to behave Outline of behaviour shaping State task/goal to child Explain necessity of procedure and steps of procedure Reinforce appropriate behaviour Disregard minor inappropriate behaviour

54. Contingency Management It is based on BF Skinner’s operant conditioning The presentation of positive reinforcers or withdrawal of negative reinforcers is termed contingency management It includes Positive reinforcement Negative reinforcement Omission or time out Punishment

55. Distraction In this method the patient is distracted from the sounds and/or sight of dental treatment thereby reducing the anxiety Objective is to relax the patient and to reduce anxiety during treatment Use of stories, fairy tales and slow instrumental music is done Externalization It is the process by which child’s attention is focussed away from sensation associated with dental treatment by involving in verbal or dental activity This is done to decrease perception of unpleasantness

56. Assimilation and Coping Stress can increase pain perception while coping decreases it by a process called as assimilation Coping refers to cognitive and behavioural efforts made by individuals to master, tolerate or reduce stressful situations Behavioural coping includes physical or verbal activities in which the child engages to deal with stress. These are readily visible to dentist Cognitive coping involves manipulation of emotions. These are not visible to dentist

57. Parental Presence or Absence The presence of parent in operatory has been a controversial issue Parents are allow in cases child has stranger anxiety or separation anxiety and special children Parents are not allowed in cases child shows tantrums in front of parents and in cases to avoid parental interference

58. Retraining This technique is designed to fabricate positive values and to replace negative behaviour The apprehension or negative behaviour may be due to previous eventful dental visit or improper parental or peer orientation The problem is located and is either Avoided or Distracted or De-emphasised & Substituted

59. Memory restructuring It is a behavioural approach in which memories associated with a negative or difficult event are restructured into positive memories It involves 4 components Visual reminder (photograph) Positive reinforcement through visualization Concrete example to encode sensory details Sense of accomplishment

60. Relaxation Breathing This method is believed to benefit fearful patient in relaxation through paced breathing It is difficult to be tense and to breathe from your abdomen at same time Visual Imagery Subject is asked to imagine being in his favourite place/performing his favourite activity and this can act as a fantasy during his dental treatment

61. Voice Control It was given by Pinkhman in 1985 Either Sudden and firm commands or soft, monotonous soothing conversation is used to get child’s attention In both cases dentist attempts to influence child’s behaviour directly and not through understanding The tone of voice and the facial expression are important Objectives: Gain attention and patient compliance Avoid negative behaviour and establish authority Indications: Uncooperative and inattentive patients

62. Hypnosis It was first suggested by Franz A Mesmer It is defined as a state of mental relaxation and restricted awareness in which subjects are usually engrossed in their inner experiences such as imagery, are less analytical and logical in their thinking, and have enhanced capacity to respond to suggestions in an automatic and dissociated manner USES : Reduces nervousness and apprehension Eliminate defence mechanisms that patients use to delay treatment Prevent thumb sucking and bruxism To induce anaesthesia

63. Hand-Over-Mouth-Technique This technique was described by Dr Evangeline Jordan in 1920 He wrote, “If a child will not listen but continues to cry and struggle— hold a folded napkin over child’s mouth and gently but firmly hold the mouth shut. His scream increases his condition hysteria but if the mouth is held closed, there is little sound, and he soon begins to reason

64. Objectives : To gain child’s attention and enable communication To eliminate inappropriate avoidance behaviour To increase child’s confidence in coping with anxiety To assure child safety in delivery of quality dental care Indication : A healthy child who is able to understand and cooperate but who exhibits defiant, obstreperous or hysterical behaviour to dental treatment

65. Contraindications Immature child When it prevents child from breathing When the dentist is emotionally involved with the child Technique When indicated, a hand is placed over child’s mouth and behavioural expectations explained. Child is told that the hand will be removed as soon as the appropriate behaviour begins. When child responds, the hand is removed and child’s appropriate behaviour reinforced. If child shows negative behaviour, the procedure is repeated

66. Protective Stabilization Partial or complete immobilization of patient is sometimes necessary and effective way to diagnose and deliver dental care Indications A patient who requires diagnosis and treatment and can’t cooperate because of lack of maturity Uncooperative patient because of mental or physical disabilities Uncooperative patient in which other behaviour management techniques have failed Combative and resistant patients so that patient, practitioner or dental staff are protected from any sort of injury

67. Contraindications A cooperative patient A patient who can’t be safely immobilised because of underlying medical or systemic conditions As punishment It should not be used solely for convenience of the staff

68. Types of restraints For MOUTH For BODY For EXTREMITIES For HEAD 1. Tongue blades
2. Mouth prop
3. Rubber bite blocks
4. Finger guards 1. Papoose board
2. Triangular sheet
3. Pedi-wraps
4. Beanbag dental chair insert 1. Posey straps
2. Velcro straps
3. Towel and tape
4. Extra-assistant 1. Head positioner
2. Plastic bowl
3. Extra assistant

69. Conscious sedation A minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacological or non- pharmacological method or a combination thereof.

70. Objectives Reduce or eliminate anxiety Reduce untoward movement and reaction to dental treatment Enhance communication and patient cooperation Raise the pain reaction threshold Increase tolerance for longer appointments Aid in treatment of medically/physically disabled patients Reduce gagging

71. Indications Lack of psychological or emotional maturity Medical, physical and cognitive disability Fearful, highly anxious or obstreperous patient A patient whose gag reflex interferes with dental care A cooperative child undergoing a lengthy dental procedure A patient from whom profound anaesthesia can’t be obtained

72. Nitrous oxide sedation It is the only one inhalation agent that meets the requirement of conscious sedation It is the most frequently used sedation agent by paediatric dentists Ideal concentration for Nitrous oxide sedation is 30% N 2 O and 70% O 2 It is safe and effective Its effect is characterised by rapid onset and fast recovery

73. Drugs used for conscious sedation Opioids (Morphine, Fentanyl) Benzodiazepines (Diazepam, Midazolam) Barbiturates (Methohexital, Pentobarbital) Propofol Ketamine Midazolam is best drug of choice for sedation in children Use of pharmacological methods should be done only after all other behaviour management modalities have proved to be unsuccessful

74. –Mc Elory (1895] “Although the dental treatment may be perfect but the appointment is a failure if the child departs in tears”