CHILD PSYCHOLOGY

& MANAGEMENT

Dr. K. Sneha
 CONTENTS

• Introduction
• Theories Of Child Psychology
• Psychologic Growth And
Development
• Factors Affecting Behavior And
Development
• Management Of Child Behavior
• Conclusion
 INTRODUCTION
• A study of psychology of childhood
if conscientiously and intelligently
pursued provides a rich
background of information about
the children’s behavior and a
psycological growth under a
variety of environmental condition.
• Psychology
is the science dealing with
human mature function and
phenomenon of his soul in the
main.

Child psychology
is the science that deals with
the mental power or an
interaction through the conscious
and subconscious element in a
 SIGNIFICANCE OF CHILD
PSYCHOLOGY IN
DENTISTRY

• To understand the child better

• To train the child effectively in his
oral habits
• To have a better treatment planning
• Detect deviations from these
patterns, which may interfere with
treatment process.
• G. STANLEY HALL - is often
referred to as “the father of child
study movement” because of his
innumerable studies on child
development.
 THEORIES OF CHILD
PSYCHOLOGY
Child psychology can be
broadly divided into two
groups:
theories of learning
psychodynamic
and development of
theories
behaviour
 PSYCHODYNAMIC
THEORIES

• Psychosexual/ psychoanalytical
theory by Sigmund Freud(1905)

• Cognitive theory by Jean Piaget(1952)

• Psychosocial theory/model of
personality development by Erik
Erikson(1963)
 THEORIES OF LEARNING
AND DEVELOPMENT OF
BEHAVIOUR
• Classical conditioning by Ivan
Pavlav(1927)
• Operant conditioning by BF
Skinner(1938)
• Hierarchy of needs by Abraham
maslow(1954)
• Social learning theory by Albert
Bandura(1963)
PSYCHOANALYTICAL/PSYC
HOSEXUAL THEORY

• Sigmund Freud(1905)
• Father of modern day
psychiatry.
• Advocated the method of free
association
 ARCHAIC DISCHARGE

• He said that the human body

contains 2 types of neurons.
• Psi neurons – For storage of
emotions.
• Phi neurons – for conduction of
emotions
• Psychic triad
Freud in 1923 made the tripartite
structural model of three
structures and hypothesized them
to understand the intrapsychic
process called as psychic triad

 Id
 Ego
 Superego
ID
• It is a collective name for the
primitive biologic impulses.
• It represents the innate portion of
the personality.
• It is a reservoir of unorganized or
unregulated instinctual drives and
energies, striving to meet bodily
needs and desires and is governed
by “the pleasure principle”.
• EGO

It is a part of self that is concerned

with the overall functioning and
organization of personality through
its capacity to test reality and
utilization of ego defence
mechanism and other functioning
like memory , language and
creativity.
Eg : hunger must wait until the food
is given.
• SUPEREGO

• That part of personality that is

internalized representation of
values and morals of society as
taught to the child by parents or
others.
 PSYCHOSEXUAL STAGES OF
DEVELOPMENT

• Freud outlined 5 stages of

manifestations of sexual
development.
1. Oral stage
2. Anal stage
3. Urethral stage
4. Phallic stage
5. Genital stage
• ORAL STAGE:

• Age: 0-1.5 years

• Erogenous zone in
focus: mouth
• Gratifying activities:
nursing, eating
biting , swallowing,
sucking.
• Symptoms of fixation:
smoking, nail biting,
drinking, sarcasm
• ANAL STAGE:
• Age: 1.5-3 years
• Erogenous zone in
focus: anus
• Gratifying activities:
bowel movement
and the withholding
of such movement.
• Symptoms of anal
fixation:
anal expulsive personality:
excessive sloppy, disorganized,
reckless, careless, and defiant.

Anal retentive personality: clean ,

orderly and intolerant to those
who are not clean
• URETHRAL STAGE:
• Age 3-4 years
• Erogenous zone: transitional
stage from anus to phallic
• Gratifying activities: pleasure in
urination
• The predominant urethral trait is
that of competitiveness and
ambition
• PHALLIC STAGE:
• Age : 4-5 years
• Erogenous zone: genital
• Gratifying activity:
genital fondling
• These derived
excitations produce
emotional and sexual
attraction for the
opposite sexed parent,
culminating in infantile
sexuality or Oedipus
complex in males (put
forth by Sigmund Freud)
Electra complex
in females (-put
forth by Anna
Fraud) which is
often dealt with
difficulty. This
stage is
complicated by
hostile and
jealous feelings
towards the
same sexed
 LATENCY STAGE
• Age: (6-12 YEARS)
• The child develops interests outside
the home.
• This is the time in elementary school
where boys have their buddies and
girls play with girls.
• The sexual feelings and behavior
seen in the phallic stage are
repressed and much of the libidual
energy is channeled through play,
hobbies and school achievements.
• This stage is the essential basis
for mature adult life of
satisfaction in world and love.
GENITAL STAGE
• Age: onset of puberty ;young adult
hood.
Just before the adolescence, with the
sharp rise in the production of
hormones, the sexual impulses are
reactivated.
• The boys become shy of girls and the
girls shy of the boys.
• But there is also the intense interest
towards the members of the opposite
sex.
 PSYCHOSOCIAL
THEORY/THEORY OF
DEVELOPMENTAL TASKS
• Erik H Erikson in 1963
• This theory postulates that, ‘Society
responds to child’s basic needs or
development tasks in each specific
period of life and states that in
doing so the society assures not
only the child’s healthy growth but
also the passage and survival of the
society’s own culture and traditions.
• Stage 1: infancy stage- age 0-1 year

• Crisis: trust vs mistrust

• In the first year of life infant

depends on others for food warmth
and affection and therefore must
be able to blindly trust the parents
or caretakers for providing these.
• Stage 2: toddler- age 1-2 years
• Crisis: autonomy vs doubt
• Toddlers learn to walk talk use
toilets and do thinks for themselves.
Their self control and self
confidence begins to develop at this
stage.
• Positive outcome: develops
confidence independence
• Negative outcome: disapproving and
overprotecting nature of parents
leads to too much doubt on his
• Stage 3: early childhood-age 2-6 years
• Initiative vs guilt
• This stage is characterized by greater
autonomy, aggressive talking, physical
activity extreme curiosity, increasing
mastery of loco motor and language
skills.
• The child is inherently teachable.
• In Erickson's view “The child’s ultimate
ability to initiate new ideas or
activities depends on how well is he /
she at this stage.
• Often the first visit to a dentist is
during this stage.
• Stage 4: elementary and middle
school years- age 6-12 years
• Crisis vs inferiority
• School is important event at this
stage. Children learn to make things
and use tools acquire skill to be a
worker, a potential provider and they
do all these while making transition
from the world of home into the
world of peers at this stage.
• Stage 5: adolescence-age 12-18 years
• Crisis: identity vs role confusion
• Who am I ?
• This is the time when we ask this
question
• Erikson suggests that adolescent must
integrate the healthy resolution of all
earlier conflicts; adolescents who have
successfully dealt with the earlier
conflicts are ready for the identity crisis
which is considered by Erikson as the
single most significant conflict a person
must face.
• It is an extremely complex stage
because of the many new
opportunities and challenge thrust
upon the teenager.
• Academic pressures, earning money,
increased mobility, career
aspirations and recreational
interests combine to produce stress
and rewards.
• This stage is extremely challenging
for orthodontists as most
orthodontics treatment is carried
out during this stage.
•.
• Stage 6: young adulthood Age 19-40
years
• Crisis: Intimacy vs isolation
• Attainment of intimate relationship with
others.
• Success leads to the establishment of
affiliations and partnerships, both with a
mate and with others of the same sex in
working toward the attainment of career
goals.
• Failure leads to isolation from others.
• There is growing number of young adults
seeking orthodontic treatment.
• Positive outcome: the adult
individuals can form close
relationships and share with others if
they have achieved a sense of
identity.

• Negative outcome: if not they will

fear commitment, feel isolate and
unable to depend on anybody in the
• Stage 7 : middle adulthood- Age 40 – 65
years
• Crisis: creativity vs stagnation
• By generativity refers to the adult’s
ability to look outside oneself and care
for others through parenting.
• positive outcome: can solve this crisis
by having and nurturing children or
helping the next generation in other
ways.
• negative outcome: people will remain
self centered and experience stagnation
in life.
• Stage 8: late adulthood- Age 65
years to death
• Crisis: integrity vs despair
• Old age is the time for reflecting
upon one’s own life and seeing it
filled with pleasure and satisfaction
or disappointment and failures
• Positive outcome: if the 7 other
psychological crisis have been
successfully resolved, the mature
adults develop the peak of
adjustment: integrity.
• Negative outcome: the opposite if
this is despair. This is often
expressed as disgust and
unhappiness on a broad scale,
frequently accompanied by a fear
that death will occur before a life
change that might lead to integrity
can be accomplished.
 THEORY OF COGNITIVE
DEVELOPMENT
• Given by Jean Piaget in 1952.
• According to jean Piaget, the
environment does not shape child
behavior but the child and adult
actively seek to understand the
environment.
• This process of adaptation is made
up of 3 functional variants.
• Assimilation - concerns with
observing, recognizing, taking up an
object and relating it with earlier
experience. Incorporation of new
environmental stimuli
• Accommodation - accounts for
changing concepts and strategies
as a result of new assimilated
information. Modification of
behavior to adapt to the new
stimuli. Piaget calls the strategies
and mental categories as
“SCHEMES”
• Equilibration Refers to changing
basic assumptions following
adjustments in assimilated
• Piaget’s marked 4 stages of cognitive
growth each characterized by a
different type of thinking and in each
child relies more upon internal stimuli.
• Sensory – motor stage -> 0-2 years
• Pre operational stage -> 2-7 years.
• Pre-conceptual thought -> 2-4 years.
• Intuitive thought -> 4-67years.
• Period of concrete operation -> 7-11
years.
• Period of formal operation -> 11 and
above.
1.Sensorimotor period:
• During this stage child develops basic
concept of object including idea that
object in the environment are
permanent and do not disappear when
the child is not looking at them
• Animism : imparting life to inanimate
objects.
• Dental application is that the child
begins to interact with the environment
and can be given toys while sitting on
dental chair in his/her hands.
2. Preoperational period:
2-7 years
Manipulation of symbols or words is a
characteristic feature of this stage
Marked inconsistencies appear in the
knowledge of child.
i. Preconceptual stage(2-4yrs)
• start of symbolic activity
• child’s reactions based on stimulus
meaning
ii) Intuitive stage(4-7years)
-prelogical reasoning appears

At preoperational period capabilities

for reasoning are limited.
Dental applications: three main
areas of focus are
1. Constructivism
2. Cognitive equilibrium
3. animism
• The glass water experiment
to identify logical reasoning
3. Concrete operation period.

• Concrete operations develop based

on the level of understanding
achieved so far.
• The thinking process becomes
logical
• Child develops the ability to
use complex mental operations
such as addition and
subtraction.

• The child is able to understand

others point of view.
4. Period of formal operation

• The child’s thinking process

becomes like adult.

• He thinks of ideas and has

developed a vast imagination.
 CLASSICAL CONDITIONING

• By Ivan Pavlov in 1927.

• Classical conditioning operates
by the simple process of
association of a stimulus with
another also called as learning
by association.
• So, how is this behavioral
conditioning related to dentistry?
• A child, by his previous bad
experience with a dentist on
white coat will associate the
pain of injection to our white
coat and become fearful and
starts crying because of
reinforcement.
THE OPERANT CONDITIONING
THEORY

• Given by B.F. Skinner

• It is an extension of classical
conditioning.
• According to this theory, the
consequences of behavior itself
act as a stimulus and affects
future behavior. Since the
behavior acts upon the
environment, it is called an
operant.
• Skinner described 4 basic types of operant
conditioning distinguished by the type of
consequences.

1.Positive reinforcement
Occurs if a pleasant consequence follows the
response.
Eg; if we dentists reward our child patients
during their first visit for being well, we can
expect a positive response next time also.
2.Negative reinforcement.
It involves removal of unpleasant
stimuli following a response.
Eg;if the child shows temper tantrums
during his first visit and become
successful , during the next visit also
he repeats it, since this behavior
have become negatively reinforced .
So it is our duty to reinforce only
desired behavior and is equally
important to avoid reinforcing
behavior that is not desired.
3. Omission
• Involves removal of a pleasant stimulus
after a particular response. Example if
the child misbehaves during the dental
procedure, his favorite toy is taken
away for a short time, resulting in the
omission of the undesirable behavior.

4. Punishment
• Introduction of an aversive stimulus
into a situation to decrease the
undesirable behavior.
 SOCIAL LEARNING THEORY

• Given by Albert Bandura in 1963.

• It deals with the basic concept
that behavior is learned.
• It suggests that the importance
of stimulus response reaction
has great significance upon the
parent’s role in child
development.
• Principle of social learning
theory
Attention: extent to which we focus on others
behaviour

Retention: our ability to retain a

representation of other’s behavior in memory

Production processes: our ability to actually

perform the actions we observe

Motivation: our need for the actions we

witness; their usefulness to us
Hierarchy of needs
 MANAGEMENT

1. Nonpharmacological
management
2. Conscious sedation
• Behavior : any activity that can
be observed , recorded and
measured.

• Behavior management : is a
means by which the dental
health team effectively and
efficiently performs treatment
for a child and at the same
time ,instills a positive dental
Role of dentist in child’s
behavior

• Appearance of dental office

• Personality of dentist
• Time and length of appointment
• Dentist’s conversation
• Reasonableness of dentist
 CLASSIFICATION OF CHILD
BEHAVIOR IN DENTAL
OFFICE
• Frankl’s classification(1962)

1. Definitely negative , rating no.1 ,

(--)
2. Negative, rating no.2, (-)
3. Positive , rating no.3, (+)
4. Definitely positive, rating no.4 , (+
+)
• Pinkham’s classification

• Category 1: emotionally compromised

• Category 2: shy, introvert child
• Category 3: frightened child
• Category 4: child who is adverse to authority

Wright’s classification:
• Cooperative behavior
• Lacking cooperative behavior
• Potentially cooperative behaviour
• Incorrigible /uncontrolled behavior
• Defiant/ obstinate behavior
• Timid behavior
• Tense cooperative
• Whining behavior
 CLASSIFICATION OF
BEHAVIOR MANAGEMENT
TECHNIQUE
PSYCHOLOGICAL APPROACH
• Pre appointment behavior modification
• Communication
• Use of second language
• Tell show do
• Tender love care
• Desensitization
• Contingency management
• Modeling
• Externalization
• Behavior shaping
• Hypnosis
• Retraining
• Distraction
• Voice control
PHYSICAL APPROACH
• Hand over mouth technique
• Physical restrains
PHARMACOLOGICAL
• Premedication
• Conscious sedation
• General anesthesia
Does audiovisual distraction reduce dental
anxiety in children under local anesthesia?
A systematic review and meta-analysis
DR JIN HUA WANG;2018

The audiovisual distraction approach

effectively reduces dental anxiety
among children. Therefore, we suggest the
use of audiovisual distraction when
children
need dental treatment under local
anesthesia.
Communication: 2 ways of
establishing verbal
non verbal
Use of second language(euphemisms)
Tell show do
• By Addleston in 1959
Desensitization
• By James and popularized by Wolpe
• Used in children having pre
established fear and uncooperative
behavior

Modeling
• Bandura’s social
learning theory
Contingency management
• Based on BF Skinner’s operant
conditioning
Types of reinforcers:
• Positive
• Negative
• time out
• punishment
Externalization:
child’s attention is focused away
from the sensation associated with
dental treatment by involving in
dental activity.

Voice control
By Pinkham in 1985
Sudden and firm commands that are
used to get child’s attention
Hypnosis
• By Franz A Mesmer in 1773
• 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.
Hand over mouth
technique
By Dr Evangeline Jordan
Other terminologies
• Aversive conditioning by
Lenchner and Wright in
1975
• Emotional surprise
therapy by Lampshire
• Hand over mouth airway
restricted by Levitas 1947
• Aversion by crammer
1973
 CONSCIOUS SEDATION

• Defined as ‘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
 SEDATION TECHNIQUES
• Inhalational sedation
• Oral sedation
• Intramuscular sedation
• submucosal sedation
• Intravenous sedation
• Rectal sedation
 NITROUS OXIDE SEDATION
• Only inhalational agent
• Frequently used
• It has low tissue solubility, and
minimum alveolar concentration
value in excess of one
atmosphere ,rendering full
anesthesia without hypoxemia
• Indications: mild to moderate
anxiety
• Contraindications: very young
child
, poor attenders, pre cooperative
children
• Precautions: diffusion hypoxia
As the sedation is reversed at the
time of termination of procedure
.the nitrous oxide escapes into the
alveoli with such rapidity that the
oxygen present becomes diluted,
thus the oxygen- carbon dioxide
exchange is disrupted and a period
of hypoxia is created.
• Conscious Sedation with Nitrous Oxide
to control Stress during Dental
Treatment in Patients with Cerebral
Palsy: An Experimental Clinical Trial
1Fernando M Baeder, 2Daniel F Silva, 3Ana CL de Albuquerque, 4Maria
TBR Santos; Int J Clin Pediatr Dent 2017;10(4):384-390.

Aim: aimed to evaluate the use of

conscious sedation with nitrous oxide
(N2O) to control stress during dental
treatment in individuals with CP using
as parameters: Venham score (VS),
heart rate (HR), and respiratory rate
(RR).
Conclusion:
• a decrease in HR,
• no respiratory depression.
• Higher concentrations of N2O
are recommended for CP
patients with tachycardia
 DRUGS FOR CONSCIOUS
SEDATION
• Opioids
1. Morphine
Sedation, analgia, and mood
alteration
DOA : 3- 4 hours
It can produce nausea , vomiting ,
itching, respiratory depression.
• Meperidine(Demerol)
One – tenth as potent as
morphine
Synthetic opioid
DOA: 2-4 hours

• Fentanyl(sublimaze)
More rapid onset and shorter
duration
100 times more potent
• BENZODIAPINES
• Diazepam(valium)
Produces amnesic, anxiolytic,
anticonvulsive and hypnotic effects
Can cause mild reduction in blood
pressure, cardiac output, peripheral
vascular resistance.

• Midazolam
Available as intravenous and oral
formulations, intranasal, rectal.
• For anxious adolescents or adult
dental patients.
• Can cause paradoxical excitement
‘Angry child syndrome’.

• BARBITURATES
General CNS depression by acting
on gaba receptors and are primarily
used when deep sedation is desired.
Methohexital
pentobarbital
 Effect of Sedation with Midazolam and
Time to Discharge among Pediatric
Dental Patients
Sigalit Blumer*/Benjamin Peretz**/Gali Zisman***/Tal Ratson****
The Journal of Clinical Pediatric Dentistry, Volume 41, Number 5/2017

The aim of this study was to examine the

recovery time of children who underwent
conscious sedation with oral or rectal
midazolam.
Conclusion: The time to discharge post-
midazolam sedation correlated to the child’s
age and weight and total amount of
administered midazolam. Sedation negatively
affected behavior in 43.6% of the cases.
• CHLORAL HYDRATE
Chlorinated derivative of ethyl
alcohol
DOA: 2-5 hours
Common complications include
nausea, vomiting, depress blood
pressure and respiratory rate and
may cause mild oxygen desaturation.
• PROPOFOL
Fast acting sedative with narrow
safety margin.
Also called as milk of amnesia.
Veerkamp et al (1997) published an
account of exploratory study where
children, mainly with nursing bottle
caries, had teeth removed using
Propofol administered by an
anesthetist.
• KETAMINE
First synthesized by Parke –
Davis scientist Calvin Stevens
and got FDA approval in 1970.
Phencyclidine derivative that
results in dissociation between
cortical and limbic systems of
brain
Dissociative anesthesia
Comparison of ketamine-Propofol
and ketamine-dexmedetomidine
combinations in children for
sedation during tooth extraction
Dilek G C et al JPakMedAssoc;2017

Ketamine-propofol might be a better

option due to lower vomiting and
nausea episodes and higher surgeon
satisfaction levels
 COMPLICATIONS
ASSOCIATED WITH
MODERATE OR DEEP
SEDATIONS
• Airway obstruction
• Anaphylaxis and
anaphylactoid reactions.
• Aspiration
• Nausea and vomiting
 CONCLUSION

•A basic knowledge of child

management is of importance to the
dentist not only in solving acute
treatment problems, but also in
developing the adult patient of
tomorrow. The child’s early dental
experiences will often be reflected in
his adult attitude towards dentistry.
• Hence every dentist should know the
emotional with social behaviour to
expect from children in different age
 REFERENCES

• Textbook of pediatric
dentistry by Nikhil Marwah;
3rd edition
• textbook of pedodontics by
Shobha Tandon ; 2 nd edition
• Pediatric dentistry by MS
Muthu, N Shivakumar
Thank you!