CHILD PSYCHOLOGY

Dr.Jeeva Priya
Dept. of Orthodontia
 Introduction
Children constitute the majority of orthodontic patients. The
most important part of treatment protocols is patient
cooperation.The ability to motivate a child patient to comply is
an essential ingredient of successful orthodontic
therapy,whether initiated in the mixed or permanent
dentition.An orthodontist can secure this cooperation only if he
understands the emotional makeup of children and to handle
them successfully he must be aware of their psychological and
sociological factors that have formed their attitudes and their
behaviour patterns .
 Child psychology is the science that deals with the mental
power or an interaction between the conscious and sub-
conscious element in a child.its main goal is to clearly
describe, predict and explain behaviour.
 Importance of Child Psychology in
Dentistry
☼ To understand the child better
☼ To promote dental attitudes
☼ To provide immediate dental needs
☼ To know the problem of psychological origin
☼ To deliver dental services in a meaningfull and effective manner
☼ To establish effective communication with a child and parent
☼ To gain confidence of the child and of the parent
☼ To teach the child and the parents ,the importance of primary and
preventive care
☼ To have a better treatment planning and interaction with the other discipline
☼ To produce a comfortable environment for the dental team to work on the
patient
 Theories of Child Psychology

CLASSIFICATION:
I. ACCORDING TO KENDELL AND ZEALEY:
1. Psychodynamic theories by
Sigmund freud
Erik erikson
Masler
2. Behavioural learning theories by
Pavlow
Skinner
Piaget
Bandura
Berne
II. ACCORDING TO JOHN WEINMAN

☼ Psychoanalytical theories
☼ Behavioural theories
☼ Cognitive theories
☼ Diological theories
III.ACCORDING TO HOWARD GARNET:
1.Cognitive-structural theories by
☼ Jean piaget
☼ Lawrence kohlberg
☼ Deanna kuhn
2. Personality (or dynamic) psychology by
☼ Sigmund freud
☼ Erik erikson
☼ Druno bettelheim
3.Behaviour modeling theories by
☼ D.F.skinner(operant)
☼ Albert Bandura(social learning)
4.Environmental learning,mediationist
☼ Tracy Kendler
☼ Alexander luria
5.Orgasmic-development theories by
☼ Heinz Werner
☼ Doughless Carmichael
6.Anthropological theories by
☼ Michael cole
☼ Margaret moad
☼ John Whiting
IV.ACCORDING TO PETER HOARE

1.Stage theories
eg.piaget,freud
2.Non-stage theories
eg. Learning theory
Stage theories have the following characteristics:
a) Each stage represents a distinctive,coherent and structured mode of
thinking, feeling, etc.,
b)Stages are hierarchically organized,so that latest stage incorporate
remnants from earlier stages.
c)sequence of stages is invariable and no stage can be skipped or
missed.
d)stages are universal,though environmental factors can modify the
form but not the structure of the stage.
e)successive stages are more complex and integrated than earlier
phases
Non – stage theories
a)Regard development as continuous rather than discontinuous, so that
they do not emphasize the distinction between periods of relative
stability and times of change.
Psycchodynamic Theories Sigmund Freud
☼ Psychoanalytical theory:
Freud in 1963 derived his ideas about personality from
working with patients with psychological problems. Very early on he
claimed that many of these problems were the result of adulthood. An
important part of his theory is therefore concerned with early
psychological development and the way in which this can influence
later behaviour

This theory is based upon the premise that child behaviour is

motivated by the need to satisfy instinctive needs. In the search to
satisfy these needs,a state of conflict develops which demands
resolution.the psychic structure proposed by Freud in this theory is
composed of three parts, ID, THE EGO and THE SUPER EGO. The
experiencing of discomfort as a consequence of the conflict between
the three components of the psychic structure is defined as anxiety
 # ID:
It is the basic structure of personality,which serves
as a reservoir of instincts or their mental representative. It
is present at birth, impulse ridden and strives for
immediate pleasure and gratification (pleasure principle)
 # SUPER EGO:
It is the prohibition learned from
environment(more from parents and authorities).It
acts as a censor of thoughts,feelings and
behaviour.It is determined by regulations imposed
upon the child by parents,society and culture.
(ethics and morals).It is the internalised control
which produces the feeling of shame and guilt.
 # EGO
It develops out of id in the 2nd to 6th month of life when the
infant begins to distinguish between itself and the outside
world;it is mediation between id and superego. Unlike id,
ego is governed by reality principle. It is concerned with
memory and judgment. It is developed after birth, expands
with age and it delays, modifies and controls id impulses on
a realistic level (reality principle)

One of the major functions of the ego is the formation of

defense mechanisms which ward off unconscious and
unwelcome instinctual impulses from the id, thus reducing
the level of anxiety
 The concept of defense mechanisms is a critical
component of the psychoanalytical theory. Defense
mechanisms are unconscious responses that an individual
makes in an attempt to cope with and reduce anxiety.
Defense mechanisms are composed of escape and
compromise techniques. The following are types of defense
mechanisms commonly employed
Projection-earliest and most primitive mechanism where the
individual projects personal feelings of inadequacy on to some
one else in order to feel more comfortable.
Eg : 1) An individual who knowingly breaks the speed limits but
later criticizes and judges the reckless driver who just passed
him.
2) An individual who calls a machine ‘stupid’ because he
cannot adequately make it perform.

Denial- is the inability or reluctance to accept the psychological

impact of a potentially stressful event or situation.
 Eg : The child denies stealing even though it is obvious that he is
responsible. This is because the open admission of the theft
would induce such a lose of self-esteem and sense of quality
that it becomes impossible, hence the use of denial.
 Undoing – Attempt to undo the harm, an individual imagines his id impulse
will produce
Eg : Superstitions such as crossing one’s fingers for luck or throwing salt
over one’s fingers for luck or throwing salt over one’s shoulder.
     Identification – Assumption of the qualities of someone else (limitation)
to vent frustration or create fantasy.
Eg : The child disciplined by an adult, who, in turn, disciplines a doll; hero
worship.
    Regression – age inappropriate response (behavioural relapse to a more
infantile manner) as a result of confrontation with an anxiety – producing
situation.
Eg : Enuresis, thumb sucking, ‘baby-talk’ in an older child upon beginning
school, moving into a new neighborhood or upon the birth of a sibling.
Reaction Formation – Transfer of hostile or aggressive impulses onto
their opposite more socially desirable form
Eg : The over concern for the welfare of his sibling may
indicate that the child has underlying feelings of jealousy and rivalry

Repression – The process of unconscious forgetting which allows for

the suppression of painful experiences into the sub-conscious mind.
This inability to recall traumatic events during childhood gave Freud a
‘catch-all’ explanation for his concepts which were difficult to prove
of disprove
Eg : An individual does not recall traumatic episodes in his
toilet training which led to a comparative adult behaviour
Rationalization – it is a strategy to excuse or minimize the psychological
consequences of an event
Eg: “I didn’t want it anyway, refusing to compete because of the fear of
failure”

Sublimation – The redirection of socially unacceptable drives into socially

approved channels to allow the discharge of instinctive impulses in an
acceptable form.
Eg: (1) Exhibitionist who becomes an actor
(2) Sadist who becomes a butcher

  Displacement – is the transfer of hostile or aggressive feelings from their

original source to another person equally less important
Eg : A school child may be aggressive in the playground with other pupils
rather than be aggressive towards the teacher in the classroom
Oedipus complex
Young boys have a natural tendency to be attached
to the mother and they consider their father as their enemy
Electra complex
The young girls develop an attraction towards their
father and they resent the mother being close to the father
 Psycho sexual theory
BIRTH ORAL STAGE ANAL STAGE

Is the 1st experience to effect In infants the oral cavity is the During this stage, maturation of
personality development site for identifying needs neuromuscular control occurs.
It therefore serves as an Control over sphincters
erogenous zone particularly anal sphincter results in
increased voluntary activity.

Abrupt change at birth result in This is a dependent stage since Development of personal
psychophysiological emergency the infant is dependent on adults for autonomy and independence.
reactions (protective shell) similar to getting his oral needs fulfilled Child realizes his control over his
fear and anxiety. needs and practices it with a sense
The characteristics are observed in of shame or self-doubt.
later life during personality
development and depend on child’s
susceptibility during this period.
If the neonate gets used to the stimuli
he is no longer anxious.

These reactions help the child to Satisfaction of oral desires The child realizes the increasing
learn some adaptive mechanisms e.g.suckling of milk by mother, voluntary control, which provides
against anxiety generating stimuli. help in development of trust him with the sense of independence
In later period of life results in and autonomy
successful achievements of needs.
Uretheral Stage Phallic Stage Latency Stage Genital Stage

It is a transition The stage begins during the Resolution of any defects Psychosexual
between the anal 3rd year of life till the 5th year occurs in this phase development extends
stage and the The phase ends in Puberty from 11 to 13 yrs. To
Phallic stage young adulthood

The child It is characterized by Maturation of ego takes Sense of identity

derives pleasures Oedipus complex place develops.
from exercising Castration anxiety There develops a greater Child has a matured
control over the degree of control over personality
urinary sphincter. Penis envy
instinctual impulses He can satisfy genital
Electra complex
Child gains better sense of potency and realizes his
There is an increase in genital initiative & starts adapting to goals for reproduction
masturbation, accompanied with the adverse environment and survival
unusual fantasies about opposite
sex

The objectives The child realizes the sexual The goal of this phase is the Matures the personality
are similar to qualities with out further development of of the individual.
those of anal embarrassment personality Helps to separate from
stage. Resolution of the stage in Consolidation of sex roles the dependence on
regulation of drive impulse. occurs. parents.
These result in maturation of Their acceptance of
ego and mastery over skills adult role, functions with
social expectations and
cultural values.
 Erik Erikson’s Psychosocial Theory

Erikson (1965), a trained psychoanalyst, gave developmental

theory of social and cultural dimension, hence his term psychosocial
other than psychosexual. He elaborated a phase or stage theory
covering the while life from birth to death. Each stage had a
development laser with access of failure polarized as two extremes of
opposites. Like Freud, he believed that the unresolved residence of
earlier phase had a continued impact on later adjustment and on
successful resolution of subsequent phases. For example an
unsatisfactory first phase leading to a basic sense of mistrust rather
than trust is likely to cause major problems with personal relationships
in later life.
ERIKSON’S “EIGHT AGES OF MAN”
 Erikson’s Psychological Stages
Erikson divided the life of man into eight stages
from birth to death.
 Basic trust versus mistrust –
The infant forms the first trusting relationship with the
caregiver.
 Autonomy versus shame, doubt
The toddler begins to push for independence
 Initiative versus guilt
The child becomes more assertive, resulting conflict
causes guilt.
 Industry versus inferiority
 The child must learn basic cultural skills such as school skills.

 Identity versus role confusion

 The child a teenager now must realize who he is and what he shall

become.
 Intimacy verus isolation
 The adult realizes the needs for one truly intimate relationship.

 Generativity versus stagnation

 The adult rears children or performs creative act failing which

stagnation occurs.

 Ego integrity versus despair

 The adult integrates earlier stages and achieves sense of integrity.
Abraham Masler’s Hierarchy of Needs
Abraham Masler’s Hierarchy of Needs

This theory developed a classification of the individual’s priority

of needs and motivations during personality development. A five
level triangular hierarchy of these needs from the most basic and
important to the most elaborate, shows a trend from instinctive motive
to more rational, intellectual ones.

 Level I (Physiologic Needs)

Includes those needs essential to survival such as reproduction,
hunger, thirst, fear etc.,
 Level 2 (Security)
Includes the need for shelter and employment.
 Level 3 (Social)
Incorporates the need to be loved and have a sense of belonging. 
 ABRAHAM MASLER HIERARCHY OF NEEDS
Cont

 Level 4 (Esteem)
 Includes a person’s need to acquire personal worth, competency

and skills.
 Level – 5 (Self Actualistion)
 Is the obtainment of realization of self.

Self actualization means the ability to use one’s capacities to good

purpose, to become fully absorbed in what one deems important, and to
do so in a lively yet selfless manner. Masler considers self-actualized
individuals to be fully human.
Consider the relationship of this theory to the motivation of patients
towards maintenance of oral hygiene practices
Jean Piaget (1952) Theory of Cognitive Development

Jean Piaget, a Swiss psychologist, has elaborated the

most comprehensive theory of cognitive development.
Many of his conclusions were based on experiments
conducted on his own children over a number of years.

Piaget’s theory is a well elaborated stage theory of

development set within a biological framework. Survival of
the fittest and most adaptable is the driving force underlying
development. Accordingly, in order to survive, the
individual must have the capacity to adapt to the demands of
the environment. Cognitive development is the result of
interaction between the individual and the environment.
Four factors influence cognitive development

☼ Progressive neurological development enables the child

to appreciate new aspects of experience and to apply more
complex reasoning
☼ The child has the opportunity for social interaction and
to benefit from schooling.
☼ The child has the opportunity to practice newly acquired
skills.
☼ Internal psychological mechanisms or structures emerge
that allow the child to construct successively more complex
cognitive models based on maturation and experience.
 Piaget’s major concepts

He proposed two types of cognitive structure, schemes and

operations, to explain the process of development. Schemes -are
relatively simple mental structure present from birth onwards. They
are the internal representations of some specific action or behaviour.
Typical examples are sucking or grasping reflexes. By contrast,
Operations- only arise much later in cognitive development and are
considerably more complex. They represent internal structures of a
high order which have the distinctive features that they are reversible.
For eg: multiplication is reversible by division.
 The child adapts his cognitive structure to the demands of the
environment through two main processes, Assimilation and
Accommodation. The assimilation refers to the incorporation of new
objects, thoughts and behaviour into existing structures, whereas the
accommodation describes the change of existing structures in response
to novel expertness. A third structure, equilibration, is the means by
which the individual balances the competiting forces of assimilation
and accommodation. In general, child attends and learns to adapt to
his environment most easily when there is a degree of novelty in the
environment which challenges his curiosity, but which is not so
strange that it becomes too confusing.
 Piaget’s Stages of Cognitive Development
Sensorimotor Pre-Operational Stage Concrete Operation Formal Operation Stage
Stage
Every child is born with Primitive strategies The thinking process The child now a
certain strategies for change as the child becomes logical. teenager is able to think
interacting with the assimilates new still more abstractly.
environment He develops the
experiences and ability to use complex He can consider a
These primitive strategies
accommodates original mental operations such hypothetical situation.
mark the beginning of the
strategies. as addition and
thinking process. Uses inductive or
The child does not yet The child uses subtraction. deductive logic to make
have the capacity to symbols in language The child is able to decisions and solve
represent objects or people and play. understand others point problems.
to himself mentally.
He learns to classify of view. He thinks of ideas and
As maturation progresses things.
the simple reflexes begin to Concrete operations has developed a vast
be coordinated e.g.looking He solves problems as develop based on the imagination.
along with arm movements a result of intuitive level of understanding
resulting in hand watching. thinking but cannot achieved so far.
By 10th month, variety of explain why
elementary schemes
develop
Object permanence
develops in course of co-
ordinating actions &
repeated contacts with
environment.
 Ivan Pavlov (1927) – Classical Conditioning

The concept of classical conditioning, based upon a stimulus –

response reflex, was developed by Pavlov’s experimentation with dogs
and provided a springboard for the behaviour learning theorists.
A stimulus – response reflex is an involuntary response to an external
stimulus. Pavlov proved that two events, observed to occur together
(Proximity in time and space), will tend to be associated or paired
together by the observer (i.e.,pairing of initial and neutral stimuli).
Through pairing, the control of the response reflex can be shifted from
one stimulus to another such that eventually a neutral stimulus alone
will elicit the response reflex. The development of a conditioned
response indicates that simplified learning process has occurred and
that the development of behaviour is controlled through the learning
process. Two examples of classical conditioning are below:
Subject Stimulus (Type) Response (Type)

Pavlov’s dog 1. Food (initial) Salivation

(Unconditioned)
2. Food (initial) + bell (neutral) Salivation
(Unconditioned)
3. Bell (neutral) Salivation ( conditioned)

Young Child 1. Sound of the handpiece Anxiety (unconditioned)

(initial)
2. Sound (initial) + dentist Anxiety (unconditioned)
(neutral)
3. Dentist (neutral) Anxiety (conditioned)
 D.F.Skinner (1938) – Operant Conditioning

Skinner pioneered the concept of instrumental (operant)

conditioning. This concept states that an individual learns to produce
a voluntary response where the consequences (outcome) are
instrumental in bringing about the reoccurrence of the stimulus. The
individual’s response is changed as a result of the reinforcement or
extinction of previous responses. Thus, the individual’s response is
reinforced by its effect upon his environment those responses which
produced a satisfactory outcome will be repeated, where as those
which met disagreeable results will tend to diminish in frequency,
Example : avoidance behaviour is reinforced by the reduction
of the fear or anxiety (Original stimulus) which brought about this
type of behaviour (response) in the first place.
 The following terms are identified with operant conditioning and are
commonly used methods of influencing an individual’s response.

1.   Reinforcement 
Any consequence of a response (outcome) that increases the
likelihood of the behaviour to reoccur in the future. It informs the child of
appropriate responses. There are two types of reinforcement.
a.       Positive reinforcement – occurs when a positive stimulus is
added after the desired response is achieved. Therefore, this response
produces an attractive outcome

2.      Extinction
Responses that are not reinforced will decrease in frequency and
be eliminated. Response which are punished appear to be extinguished but
are really only suppressed.
3. Systematic Desensitization (counter – conditioning)
A method to extinguish learned maladaptation responses by
substituting more appropriate ones. A method of reciprocal
inhibition where anxiety evoking stimuli are paired with the
stimuli that evoke responses that are incompatible with the
anxiety, as one response will reciprocally inhibit the other.

4. Reward
The result of adding positive outcomes and/or removing negative
ones.
 5.      Punishment
The result of adding negative outcomes and/or removing positive
ones, thus weakening the behaviour or response punishment is different
from negative reinforcement in that it produces rather than remove and
adversive outcome.

  In addition, there are many factors which influence the

effectiveness of punishment. These factors include.
a.   Timing – The closer the proximity of the punishment to the

occurrence of the act, the stronger is its reinforcing effect.

b.   Intensity.
c.   Relationship of the child to the punishing agent.
d.   Level of the child’s to the punishing agent.
e.  Consistency
 Therefore, punishment intentional or
unintentional, may work to control behaviour, but may
well affect the child in other ways. Unless the punishment
is very severe, its effect may only be temporary, as the
behaviour is not extinguished but rather suppressed. Mild
punishment, such as verbal or non-verbal criticism
(frowning, shaking one’s head, etc) will have more
potential for being effective as long as the alternative for
undesirable behaviour is provided.
Albert Bandura (1963) – Social Learning Theory

Social learning theory is thought to be the

most complete, clinically useful and theoretically
a sophisticated form of behaviour therapy. As
compared to Operant and Classical conditioning
this theory is:
 Less reductionistic
Provides more explanatory concepts
Encompasses a broader range of phenomena
The learning of behaviour is affected by 4 principle elements :

1.      Antecedent determinants – the conditioning is affected if the

person is aware of what is occurring.
2.      Consequent determinants – Person’s perception and expectancy
(cognitive factors) determine behaviour.
3.      Modeling – 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
-         Motivational processes
4. Self-regulation – this system involves a process of self-
regulation, judgement and evaluation of individual’s responses to his
own behaviour.
Eric Berne (1964) – Transactional Analysis
The basis of transactional analysis is founded on the development of
three specific states of being – child, parent and adult. There ego states are
defined as the three active elements in each person’s personality which
function separately or simultaneously in different situations.
 
The child ego state -is the felt concept of life and is characterized by impulse –
ridden spontaneous emotional and physical behaviour. Clues to the child ego
stage manifest as crying, pouting, temper tantrum, shoulder shrugging, teasing,
laughing, guilt and anxiety.
 
The parent ego state- is the taught concept of life and is characterized by critical
and nurturing emotional and physical behaviour. Close to identifying parent
ego states are finger pointing, head – shaking, head – patting, etc.,

The adult ego state- is the thought concept of life and is represented by the
organized, objective gathering and analysis of facts. Unlike child and parent
ego state behaviour, which is predictable and fixed, adult ego stage behaviour
is adaptable and controlled.
Emotional Development

 Emotion is a state of mental excitement characterized by

physiological, behavioural changes and alterations of
feelings. 
 Characteristrics of commonly seen emotions in a child

I.               Distress or Cry
II.              Anger
III.            Fear
IV.           Anxiety
V.              Phobia
I. DISTRESS OR CRY:

At Birth : Primary emotion present at birth with vigorous body

expressions usually due to hunger, colic or any other internal
cause.
At six month:It is greatly replaced by a milder expression of
fussing or vocalization.
During preschool: It is seen less, only for the reasons of
physical pain as he is thwarted by his environment.
During school years: Pressure helps him to outgrow the crying
habit which decreases rapidly. After this till 15 years crying
occurs very seldom.
In young adult: Ultimately it becomes a limited quiet crying in
private only for reasons of grief or other intense emotions.
 Different types of cry seen in children:

Sometimes, the different types of cries can be an

asset in diagnosing the behaviour of a child. Following
four types of crying are usually seen in children.
(Elsbach, 1963)
1.  Obstinate Cry:
The child throws a temper tantrum to thwart
dental treatment.
It is loud, high pitched.
Characterized as a siren like wail.
This form a belligerent cry, represents the
child’s external response to anxiety.
 2.      Frightened Cry.
Usually accompanied by a torrent of tears.
Convulsive breath-catching sobs.
Usually the child emitting this type of cry has been over-whelmed by
the situation.
  3.      Hurt Cry
May be loud, more frequently.
Frequently accompanied by a small whimper.
Initially a child in discomfort shows a single tear filling from the
corner of the eye and running down the child’s cheek without making
any sound or resistance to the treatment procedure.
4.      Compensatory Cry
It is not a cry at all.
It is a sound that child makes to drown out the noise for example a
drill.
Usually the cry sound is slow, monotone.
It is a sort of coping mechanism to unpleasant auditory stimuli,
finding himself uncomfortable in the situation.
 II. ANGER
Outburst of the emotion is caused by the child’s lack of skill in handling the
situation. Infants and young children respond in anger in a direct and primitive manner
but as they develop the responses become violent and more symbolic.

For example
15 months children express anger by throwing objects.
Two years olds attack other children with an intention to hurt.
Four years old, have less expression of anger.
Six years old have renewal of violent methods of expression of anger.
Seven years ones display less aggressiveness, though kicking, throwing objects is
observed.
8-9 years olds anger is expressed through feelings. It becomes directed towards a
single person.
10 years olds anger may become violent and may be expressed phycially.
12 years olds express anger verbally
14 years olds may take out his anger on someone else.
 III .FEAR

Fear is a reaction to a known danger (augmenting the

fight or flight response). Its source is the consciousness.
It may be defined as an unpleasant emotion or
effect consisting of psychophysiological changes in
response to realistic threat or danger to one’s own
experience.

Prevalence of Fear
  Various studies have found the incidence of dental fear
to be 3-21%, depending on the age of the child.
Girls have been reported to have more fears than boys.
Several reasons suggested are:
An inherent timidity in girls.
Girls are encouraged to display fear while boys are encouraged to hide it.
The fears have also been reported to increase from infancy to young
childhood. At the same time, the type of fear varies at different ages such as:
 
Development of fear:
a.  At birth:
This is primary response acquired soon after birth such as a startle response,
however, the newborn is unaware of the stimulus.
With age he starts becoming aware of fear producing stimuli and can adjust
to the isolated experience by resorting to flight if he cannot solve the problem.
Sometimes, the smells and sounds of equipment or even the appearance of
dentist with glasses and mask may be frightening.
 b.      Pre schooler(2-5years)
Fear of animals or being left alone or abandoned.
More apprehensive about failures, learns to fear his prestige.
c.      Early schooler
Fear of the dark, staying alone. Shows fear of supernatural powers
like ghosts and witches, imaginary objects and situations such as fear
of war, spies, beggars, etc.,
d.       Late schooler
By age of 9, fear of bodily injury may be present
 Fear of failure, not being liked, competition, fear of punishment.
Fear of crowds, heights.
e.      Adolescent
Fear of social rejection and fear of performance
(peer group pressures, academic pursuits).
Fear of Dental Situation
It is observed that fearful patients usually report a history of
traumatic dental experiences. Unfavourable family attitudes and
transmission of these may also result in fear. Thus, various types of
fears can be observed in the clinic as:

I. Innate fear: (without stimuli or previous experience) : It is thus

also dependent on the vulnerability of the individual.
II.Subjective Fear: Fears transmitted to the individual are termed
subjective fears. They may due to :
-Family experiences, peer (friends), information media
(TV, papers, comics).
III Objective Fear : Fears due to events, objects and specific
conditioning. Previous experience (dental trauma) or generalization
(medical experience).
 Fear Evoking Dental Stimuli
Various dental stimuli evoke fear. It is observed that the most
feared events in the dental clinic can be ranked as:
Anaesthetic administration locally by injection.
Extraction
Sound of drill.
 
Factors Causing Dental Fear
An interaction of various factors occurs in the existence of
dental fear such as:
1. Fear of pain or its anticipation.
2. A lack of trust or fear of betrayal.
3. Fear of loss of control
4. Fear of the unknown
5. Fear of intrusion.
Features of Fear
Fear is a package of reactions that tend to occur
together simultaneously or sequentially. About 70%
children acquire dental fear at early age. This emotion
may present the following main two expression:

 1.   Tendency to freeze which reaches its extreme in the

form of death.
 2.   Startle, scream, run away from the scene of danger,
i.e.flight.

It turns, a shift from freeze reaction to flight.

 Symptoms of Intense Fear:

Unpleasant feeling of terror.

An urge to cry or hide.
Pounding of the heart.
Tense muscles.
Liability to startle.
Dryness of the throat and mouth.
Sinking feeling.
Urge to urinate (very common in children)
Irritability.
Anger
Weakness
Sense of unreality.
 Chronic fear leads to
Tiredness.
Difficulty in sleeping and bad dream.
Restlessness
Loss of appetite
Aggression
Avoidance of tension producing situation.

Physiological Sign of Fear

Pale sweaty skin.
Hair standing on end
Dilation of pupils
Rapid breathing.
Increased heart-rate.
Raising blood pressure.
Increased blood flow through muscles.
Contraction of the bladder and the rectum.
 Biochemical Changes in Few Minutes
Secretion of adrenaline.
Secretion of noradrenaline.
Increase in free fatty and corticosteroids in plasma

Response to fear
It can be described at three level:
1. Intellectual level: Where the child is ready to accept the situation and
face the difficulties to achieve results and benefits (usually seen at
adolescent age).
2. Emotional level: Usually the child shows the fight or flight
response,which acts as an instantaneous response(seen in school age).
3. Hedonic level: Usually reflected as self centeredness, thereby accepting
what is comfortable and rejecting what is not without too much concern
for the outcome or nature of the treatment (may be seen in a very young
children). It may be expressed through somatic complains or chronic
fatigue in the elderly group.
 IV : ANXIETY
Is an emotion similar to fear but arising without any objective
source of danger.
Is a reaction to unknown danger.
It is often been defined as a state of unpleasant feeling combined
with an associated feeling of impending doom or danger from within
rather than from without.
It is a learned process being in response to one’s environment. As
anxiety depends on the ability to imagine, it develops later than fear.

Sub-types of anxiety
 Association :
This is a process of classic conditioning whereby previously
neutral stimuli become the cause for arousal and anxiety by pairing
them with pain or the negative experiences of others.
 Cause of Anxiety
Uncertainity
Fear of unknown is anxiety provoking. In dental clinic, new patient’s
anxiety can be due to the uncertainity they feel about what awaits them affer
initial first appointment check up.
 
Previous learning
In such cases anxiety is present due to their previous learning
experiences of trauma during the first visit or the learning involved in dental
anxiety may have been more indirect, depending upon the experience of other
people. Maternal anxiety plays an important role in the child’s anxiety level
determinant. A mother with higher anxiety, will have a child usually showing a
negative behaviour as a result of his high level of anxiety.
Biological difference
Some people are more predisposed to become more anxious or to learn
about anxiety responses than others due to the innate biological mechanism.
 Types of anxiety
Trait anxiety
Is a lifelong pattern of anxiety as a temperament feature. These
children are generally jittery, skittish, hypersensitive to stimuli.
 
State anxiety
Are acute situationally bound episodes of anxiety that do not persist
beyond the provoking situation.
 
Free floating anxiety
Is a condition of persistently anxious mood in which the cause of
emotion is unknown and many other thoughts or events trigger the
anxiety.
Situational anxiety
Where the individual experiences a chronic pervasive feeling of
anxiousness whatever the external circumstances.
Anxiety Rating Scale:
The patient’s anxiety can be evaluated through the following
scales:
I. Pictorial and Response Card
The scale evaluates the child’s fear in the dental set-up in different
situations such as:
 -         appointment with the dentist

 -         waiting for his turn in the dentist’s office

 -         dental procedures

 -         lying on bed dreaming about the dentist, etc.,

The scale gives 5 options graded 0 – 4 , from relaxed to panic

behaviour depicted by various pictures
 0-     relaxed

 1-     uneasy

 2-     feeling scared but cooperative

 3-     feeling scared and uncooperative

 4-     feeling very scared, uncooperative, requires physical restrain.

 
The child is shown pictures and encouraged to represent his feelings
 Verbal Questions
The child is asked questions or given “sentence completion
tasks” to verbalize his fear. Negative or reluctant answers imply fear
while positive opinions imply  non-fearful child.

II. Questionnaire
Anxiety can also be evaluated by answers to the
questionnaire given to the child patient and the parent.
The questions help to determine the attitude and
experiences of both the patient and parent.
 V : PHOBIA
Is an irrational fear resulting in the conscious
avoidance of a specific feared object, activity or situation

It may be defined as a persistent, excessive,

unreasonable fear of a specific object, activity or situation
that results in a compelling desire to avoid the dreaded object.

Characteristics of phobia
Being out or proportion to the stimulus or situation
(not age appropriate).
Cannot be reasoned with
Being out of voluntary control.
 Persistent and unadaptable
Types of Phobia
Shelhan (1982) divided anxiety and phobia into two major groups.

  1. Exogenous (non-endogenous)
2. Endogenous
 
1.Non-endogenous(EXOGENOUS):
This is a psychologically affected group who involve a situation related
anticipatory anxiety symptoms such as:
Moist palms
Fluttery stomach
Fine hand tremors
Shaky inside
Rapid heart beat
  These are the symptoms seen when normal individuals are stressed or
threatened. The main cause is in the external environment. It is an anxiety or phobia
due to a factor “to be produced from the outside”. Thus, the individual can readily
identify the etiological agent.
 2.Endogenous

This anxiety is present without any prior warning or the presence of any
detectable stress situation. The cause is “to be produced from within”. This
type of anxiety has a more severe cluster of symptoms such as:
Light headedness or dizziness.
Difficulty in breathing
Parasthesia
Hyper-ventilation
Chest pain
Losing control
 
3. Other cause of Phobia
Based on the causative factor they can be classified into three major
categories: 
1. Simple Phobia
  Is an isolated fear of a single object or situation leading to avoidance of
the object of the situation. The fear is irrational and excessive but not always
disabling. Some of the phobias are : 
 Acrophobia - Height
 Agoraphobia - Open space
 2.Situational Phobia:
  Is popularly interpreted as a fear of open space, but has wider
implications. It usually refers to a cluster of complaints. In
addition to open or crowded places they also fear public transport,
bridges, tunnels, being alone at home or being away from home
etc.,
 Characteristics
Dizziness, loss of bladder control or bowel control, cardiac
distress.
 
3. Social Phobia:
Is basically phobia due to the fear of being looked at and
the concern about appearing shameful or stupid in presence of
others. Main types of social phobia are public speaking, fear of
eating, fear of blushing.
Phobia in Childhood
 
The most common phobia in childhood is the fear of animals. This
usually comes on between the age of 2 and 4 and is gone before the age
of 10 years.
 Another common phobia is of darkness, a fear experienced by children
between the age of 4 and 6 years. This is most likely due to the
imagination of the child as to various creatures lurking out in the dark.
School phobia is an exaggerated fear of attending school and occurs in
all children peaking around 11-12 years. A fear of various activities
connected to school such as new faces and challenges, fear of leaving
home.
In 12 years children of both sexes, previous aversive dental experiences
are more closely related to dental phobia than general fear.
At adolescent period most children outgrow their fear. Two phobias
commonly seen are fear of blushing and fear of being looked at.
 BEHAVIORAL SCIENCE AND ITS
APPLICATION:

Behavior -is defined as any change in the functioning of the organism

Behavioral pedodontics- is the study of science, which helps to under
stand development of fear anxiety and anger as it applies to child in dental
situation.
 
Classification of child behavior:
  Wilson’s classification:
a) Normal or bold : the child is brave enough to face new situations, is
cooperative , friendly to the dentist.
b) Tasteful or timid: the child id shy, but does not interfier in
dental procedures.
c) Hysterical or rebellious: Child is influenced by home
environment throws temper: tantrums and rebellious.
d) Nervous or fearful : the child is tense and anxious, fears dentistry.
 Frankel’s classification (1962):

Rating Behavior
1. Definitely negative (- -) Refuses treatment, cries
forcefully.extremely negative
behaviour associated with fear

2. Negative (-) Reluctant to accept treatment and

displays evidence of slight negativism

3. Positive (+) Accepts treatment,but if the child has a

bad experience during treatment,may
become uncooperative

4. Definitely positive (+ +) Unique behaviour,looks forward to and

understands the importance of good
preventive care
LAMPSHIRE(1970)

CO-OPERATIVE: The child is physically and emotionally relaxed and is

co-operative throughout the entire procedure.
TENSE COOPERATIVE: The child is tensed, and cooperative at the same time
OUTWARDLY APPREHENSIVE: Avoids treatment initially,usually hides behind the
mother, avoids looking or talking to the dentist.eventually accepts dental
treatment.
FEARFULL: Requires considerable support so as to overcome the fears of dental
treatment
STUBBORN/DEFIANT: Passively resists treatment by using techniques that have been
successful in other situations
HYPERMOTIVE: The child is acutely agitated and resorts to screaming, kicking, etc..
HANDICAPPED: Physically / mentally, emotionally handicapped.
EMOTIONALLY IMMATURE
CLASSIFICATION GIVEN BY WRIGHT(1975)
A.COOPERATIVE(POSITIVE BEHAVIOUR)
a) cooperative behaviour: child is cooperative,relaxed with minimal
apprehension.
b) lacking cooperative ability: usually seen in young child,
(0-3yrs), disabled child,physical and mental handicap.
c) potentially cooperative:has the potential to cooperate,but because
of the inherent fears (subjective/objective) the child does not
cooperate
B.UN-COOPERATIVE(NEGATIVE BEHAVIOUR)
a)uncontrolled/hysterical/incorrigible - usually seen in:
- preschool children at their first dental visit
- temper tantrums.e.g. physical lashing out of legs and arms, loud crying and refuses
to cooperate with the dentist.
b) defiant behaviour/obstinate behaviour
- This type can be seen in any group.
- Usually in spoilt or stubborn children
- These children can be made cooperative
c) tense co-operative:
- these children are the borderline between positive and negative behaviour.
- does not resist treatment but the child is tensed at mind.
d) timid behaviour/shy:
- usually seen in overprotective child at the first visit
- is shy but co-operative
e)whining type:
- complaining type of behaviour allows for treatment but complains
throughout procedure.
f) stoic behavior:
- seen in physically abused children.they are cooperative and passively accept all
treatment without and facial expression.
 Factors which affect child behavior in dental office
Under the control of dentist Out of control of the Under the control of
dentist the parents
Effect of dental office Growth and Home environment
environment development
Effect of dentist’s activity and Nutritional factors Family development
attitudes and peer influence

Dentist’s attire Past dental experience Maternal behavior

Presence / absence of parents in Genetics

the operatory

Presence of an older sibling School environment

Socioeconomic status
 Under the Control of the Dentist
I. Dental clinic:
1.      Dental office should be warm and stimulate a homely environment.
2.      Healthy communication with the child should be established
3.      The operating environment should be made colorful and lively with posters.
4.      Dental auxillary should be kind to the children and should greeet them with a smile.
5.      Appointment time should always be short, i.e. less than 30 – min.
6.      Early morning appointments.
 
II. Effect of dentist’s activity and attitudes.
1. The dentist should form a good impression on the child.
2. Jenks (1964) has described six categories of activities by which the
dentist can foster or enhance cooperation in children. They are
 a. Data gathering and observation

 b. Structuring

 c. Externalization

 d. Empathy and support

 e. Flexible authority

 f. Education and training

 Out of control of the Dentist

Growth and development

If there is a deficiency in physical growth and development or
congenital malformations. Eg. Cleft lip
Mental retardation, epilepsy, cerebral palsy etc. make the child
mentally handicapped.
Nutritional factors
Studies have shown that an increased intake of sugar causes
an irritable behavior
Hypoglycemia causes a criminal behavior
Skipping breakfast leads to an impaired performance
Nutritional deficiency also affects the mile stones of biological and
cognitive development
Past medical and dental experiences
Genetics
There should be a constant interaction between genetic
programme of the child and environment for the psychological
development of the child
School environment
Socio-economic status
High socio-economic status child may develop normally
because the family can provide all the necessary requirements.
A low socio-economic status – child develops resentment
and is tensed as the child gets little attention and is often neglected.
 Under the control of the parents

Home environment:
 The home is the first school where a child learns to behave.

i.e. in case of a broken home, the child may feel

insecure, inferior, apathic and depressed.
 Postnatal behavior of the child depends on the prenatal
emotional status of the mother.
Family development and peer influences:
 Position of the child, status of the child in the family,
parental attitudes can influence the child’s behavior.
 Internal family conflicts affect children’s behavior.
Maternal behavior:
Maternal influence on the children’s mental, physical and
emotional development begins even before birth.
 Maternal attitude and child’s behavior

Mother’s behavior Child’s behavior

Overprotective dominant Shy, submissive, anxious

Over indulgent Aggressive, demanding, display of

temper tantrums

Under affectionate Usually well behaved, but may be

unable to cooperate, shy, may cry
easily
Rejecting Aggressive, overactive, disobedient

Authoritarian Evasive and dawdling

 BEHAVIOUR MANAGEMENT

Definitions:
 
Behaviour management: is defined as the means by which the dental health team
effectively and efficiently performs dental treatment and thereby instills a
positive dental attitude
 
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: is defined as the attempt to alter human behaviour with
the laws of learning.
 
Behaviour management can be classified as:
 
Non pharmacological
 Pharmacological
Non-pharmacological methods of behaviour management.
1.      Communication
2.      Behaviour shaping (modification)
i. Desensitization
ii. Modeling
iii. Contingency management
3.      Behaviour management
i. Audio analgesia
ii. Biofeed back
iii. Voice control
iv. Hypnosis
v.  Humor
vi. Coping
vii. Relaxation
viii. Implosion therapy
ix. Aversive conditioning
Pharmacological method of behaviour management
 
PRE-MEDICATION
 Sedatives and hypnotics

 Anti-anxiety drugs

 Antihistamines

 Conscious sedation

 General anesthesia

 
COMMUNICATION
 Communication should be comfortable and relaxed.
 Verbal communication is the best for younger children is best for
more than 3 yrs of age
 Voice should be constant and gently
 Patient always prefers to be addressed by his name
 Sitting and speaking at a high level allows for friendly atmosphere.
 USE OF EUPHEMISMS – substitute words e.g. anesthetic solution is
referred to water, which is used to put teeth to sleep.
BEHAVIOUR SHAPING (MODIFICATION)
This is a step by step procedure to make the child involved in dental
therapy

Desensitization – it is accomplished by teaching the child a competing

response such as relaxation and the introducing progressively more
threatening stimuli.

Method
Tell Show Do technique (TSD)
 Addleslon 1959, introduced the concept of Tell, Show, Do
Tell and show every step and instrument and explain what is going to
be done. Continuously and in grades from the least fear promoting
object or procedure and move in higher grades to more fearful objects.
By having verbal (tell) and nonverbal (show and do) interactions,
available, one can over come the many small dental related anxieties of
any child.
2. Modeling
Introduced by Bandura (1969) developed from
social-learning principle procedure involves allowing a
patient to observe one or more individuals (models) who
demonstrate a positive behavior in a particular situation.
Therefore the patient will frequently imitiate the models
behavior when placed in a similar situation. Modeling can
be done by:
a. Live models – siblings, parents of child etc.
b. Filmed models
c. Posters
d. Audiovisual aids
3. Contingency management
It is a method of modifying the behavior of children by presentation or
withdrawal of reinforces. These reinforcers can be:
a.      Positive reinforcer : is one whose contingent
presentation increases the frequency of behavior
b.      Negative reinforcer: Negative reinforces is usually a
termination of an aversive stimulus e.g. : withdrawal of the mother.
Types of reinforcements can be:
a.      Social: for e.g. praise, positive facial expression, physical
contact by shaking hand, holding hand, and patting shoulder or back.
b.      Material : may be given in the form of toys, games.
Sweets are not given – as reward since it causes caries.
c.       Activity reinforces: involving the child in some activity
like watching a TV show/special programmes with him. For the benefit
of contingency management social reinforces are the most effective.
Behaviour management
Behaviour management should go hand in hand with the hand piece skills
and knowledge of dental materials for the successful treatment of children

☺ Child can be managed by the following methods :

Audio analgesia: or “white noise” is a method of reducing pain
(pleasant music)
Biofeed back : involves the use of certain instruments to detect certain
physiological processes associated with fear.
Humor : helps to elevate the mood of thee child, which helps the child to relax.
Coping: It is the mechanism by which the child copes up with the dental treatment

Coping effect may be of two types

Behavioural: are physical and verbal activities in which the child engages to
overcome a stressful situation.
Cognitive : The child may be silent and thinking in his mind to keep calm.
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
Relaxation : This technique is used to reduce stress and is based on the principles
of elimination of anxiety. (exercises)
Hypnosis : Hypnosis is an altered state of consciousness characterized by a
heightened suggestibility to produce desirable behavioral and physiological
changes.
Implosion theray : Implosion therapy mainly comprises of HOME, voice control
and physical restraints
Aversive conditioning:
Aversive conditioning can be a safe and effective method of
managing extremely negative behavior.
Parental consent two common methods used in the clinical practice
are HOME and physical restraint:
 A.HOME: (Hand over mouth exercise)
The behavior modification method of aversive conditioning is also known as HOME.
Introduced by Evangeline Jordan 1920
 
The purpose of HOME is to gain the attention of a child so that communication can be
achieved.
Indications :
A healthy child who can understand but who exhibits defiance and hysterical
behavior during treatment.
3-6 years old.
A child who can understand simple verbal commands.
Children displaying uncontrollable behavior.
Technique : After determining the child’s behavior, the dentist firmly places his hand over
the child’s mouth and behavioral expectations are calmly explained close to the child’s
ear. When the child’s verbal outburst is completely stopped and the child indicates his
willingness to co-operate, the dentist removes his hand. Once the child co-operates, he
should be complimented for being quiet and praised for good behavior. It should be
noted that the child’s airway is not restricted while performing the technique and the
whole procedure should not last for more than 20-30 sec.
B. Physical restraints: Last resort for handling
uncooperative patients or handicapped patients

Physical restraints involve restriction of movement of the

child’s head, hands, feet or body. It can be
Active – restraints performed by the dentist, staff or
parent without the aid of a restraining device.
Passive – with the aid of restraining device
 Child abuse and neglect
Child Abuse
○ Any non accidental physical, sexual of emotional act against a child
by a parent or caretaker. That is beyond the level of childcare, is
termed as child abuse.
Neglect
○ When a child lacks proper support, education, nutrition and health
care, called as ‘neglect’
○ The first reported case of child abuse occurred in 1874
○ Henry kempe in 1962, described “bettered child syndrome”
◦ Fracture of long bones
◦ Subdural haematoma
◦ Failure to thrive
◦ Soft tissue swelling
◦ Skin bruising
Types of child abuse and neglect:
◦ Physical abuse
◦ Sexual abuse
◦ Failure to thrive
◦ Intentional drugging
◦ Health care neglect
◦ Dental neglect
◦ Safety neglect
◦ Emotional abuse
◦ Emotional neglect
◦ Physical neglect
◦ Education abuse
Child psychology in application to oral habits

Almost all normal children engage in prolonged sucking

habits which can lead to malocclusion. It is first important for an
orthodontist to differentiate children with habits of potential
psychological disturbance & those that have ‘empty habit’. If habits
persist beyond the primary dentition there could be potential harm to
the developing occlusion

Theories which explain this

Psychoanaltic theory – Mostly children out grow the need for non
nutritive sucking by 3 years of age & children who continue beyond
this age have some underlying psychological disturbance
Learning Theorists : considered non-nutritive sucking to be a learned habit
and do not believe it is necessarily a sign of psychologist’s problem

While deciding to treat thumb sucking an orthodontist should

consider the attitude of the child - in all instances it is important for the
child to be involved in the decision making so that the child does not make
the intervention as a punishment. Treatment options can also involve
relaxation
○ mental imagery,

○ behaviour modification such as using rewards,

encouragement & reminders.
○ Parent counseling is mandatory in case the orthodontist suspects
the presence of emotional problem
 SCIENTIFIC ARTICLE – PEDIATRIC DENTISTRY VOL 24, No. 2

THE EFFECT OF MUSIC DISTRACTION ON PAIN ANXIETY AND

BEHAVIOUR IN PEDIATRIC DENTAL PTS.

PURPOSE :
 
To determine if audio distraction could reduce the child’s anxiety,
pain & disruptive behaviour during procedures. 45 children between
4-6 yrs had two visits involving restorative dentistry with LA 
 
CONCLUSION:
Audio distraction was not an effective method of reduce anxiety, pain or
unco-operative behaviour during the procedure. However, patients did enjoy
listening to music during their visits.
 
II. LACK OF CO-OPERATION IN PAEDIATRIC DENTISTRY – THE ROLE OF
CHILD PERSONALITY CHARACTERS.

PURPOSE:  
This study aimed to investigate fear, temperament behaviour
symptoms & verbal intelligence in a study group of unco-operative child
dental patients, partly in comparision with a reference group of ordinary child
patients. A second aim was to explore a hypothesis of hereto geneity by
searching for sub-groups within the study group.
 
Parents answered on a questionnaire. Concerning dental and general
fear, temperament & general behaviour of the children
 
CONCLUSION:
 
Unco-operative child patients constitute a heterogenous group. Sub
groups with different fear, temperament & between problem can be identified.
 Conclusion
A sound knowledge in child psychology and
behavior management is essential for a successful dental
practice. Patient co-operation which is a critical factor in the
efficacy of orthodontic treatment is to be expected only after the
dentist helps the child overcome his / her fear and anxiety. Major
treatment decisions hinge on the expected level of compliance,
and poor co-operation usually prevents the orthodontic from
achieving optimal treatment results.
 
While undergoing orthodontic treatment, the child
is expected to follow instruction daily – to wear elastics, head
gear, maintain ideal oral hygiene, endure discomfort, keep
regular appointments and refrain from eating many foods that
can be detrimental to the appliances. Therefore successful child
management can only ensure the child to be co-operative, which
in turn results in a complete and desired optimal treatment result.
Thank you