Good morning!

Presented by:-
Srishti Thapliyal (1583)
Srishti Trilokhar(1584)
BEHAVIOUR OF CHILD IN DENTAL
OFFICE.
 CONTENT:-
1. INTRODUCTION.
2. PYSCODYNAMIC THEORIES.
3. BEHAVIOR LEARNING THEORIES.
4. BEHAVIOR MANAGEMENT
5. CONCLUSION
6. REFRENCE.
 INTRODUCTION:-

Human personality is a characteristic pattern of

thoughts, emotions and behavior that define an
individual’s personal style and influence his or her
interactions with the environment.
 ASPECTS OF PERSONALITY:-
# Oral habit development.
# Fear.
# Anxiety formation.
Many theories have been proposed to explain and identify the processes involved in personality development.

These theories can be divided into two groups:-

Psychodynamic theories

Behavior learning theories.

 PSYCHODYNAMIC THEORIES:-
# Classical psychoanalytical theory by Sigmund Freud (1905)

# Developmental tasks theory by Erik Erikson(1963).

Behavior learning theories:-

1) classical conditioning theory by

Ivan Pavlov(1927).

2)operant conditioning theory by

B.F. Skinner(1938).
3) Theory of cognitive development
by Jean Piaget(1952)

4) Social learning theory by Albert

Bandura(1963).
 PSYCHODYNAMIC THEORIES:-
Classical psychoanalytical theory by Sigmund freud:-
Freud compared the human mind to an iceberg.
The small part that shows above the surface of the water
represents the conscious experience.
The larger mass below the water level represents the
unconscious store house of impulses, passions and
inaccessible memories that affects thoughts and behaviors.
WHAT HE BELIEVED IN?
He believed that unsatisfying drives
and unconscious wishes cause all
psychological events.

According to him, personality is

composed of three major systems.
 id

ego superego
 Id:-
It is the most primitive part of the personality from which the other two systems develop later( ego and superego).

It seeks immediate gratification of impulses.

Gratifications of impulses are:-
the need
to eat,
The need to
avoid pain etc.

The need
to drink,

The need to
eliminate
wastes,
 Ego:-
It is the ability to understand that their impulses cannot always be
gratified immediately comes with the development of ego.
Kids learn that hunger must wait
until someone provides food and that the satisfaction of relieving the bladder.

“So ego obeys the reality principle”

 Superego:-

The superego represents the

internalized representations of
the values and morals of the
society as taught to the child
by the parents and other
elders.
 Note:-
#In a well- integrated personality, ego remains in firm but feasible control.

#Violating the superego’s standards or even the impulse to do, produce anxiety.
Ego mechanism of defense:-

Expressing the impulses in

disguised form can avoid
punishment by the society and
thereby reduce the anxiety.
These strategies are called as the
ego’s mechanisms of defense.
Denial is an example of a defense mechanism, for example a
patient may deny the existence of an abscessed tooth because
of the anxiety associated with the necessary dental treatment.
There are many developmental stages according to freud :-

# Oral Stage.
# Anal Stage.
#Phallic Stage.
# Latency Stage.

# Genital Stage.
 ORAL STAGE:-

The first year of life is called by

Freus as the oral stage and is
characterized by Passiveness and
Dependency.

The primary zone of pleasure is the

oral region because hunger is
satisfied by oral stimulation.
Children will put their thumb or
anything else they can reach, into
receive sufficient gratification of
pleasure at this particular age,
fixation to this stage occurs as the
individuals grow older.
 Oral dependency in the form of digit
sucking habit is an example of this seen
in older individuals.
 Anal stage:-
This stage occurs between
the age 1 to 3 years and Is
marked by the egocentric
behavior.

During this stage the zone

becomes the primary zone of
pleasure.
Gratification is derived from
expelling or withholding feces.

If there is over emphasis by adults on

toilet training will result in
compulsive, obstinate and
perfectionist behavior in later life and
is called as “ ANAL PERSONALITY”
NOTE:- Less controlled toilet training results
in an impulsive personality in later life
Phallic stage:-
Sex identification which occurs between 3
and 6 years of age (this is an hallmark
feature of it).

The children begin to direct their

awakened sexual impulses towards the
parent of the opposite sex.
This character observed in males is
called “Oedipus Complex”.
This complex is characterized by the
tendency of the young child boy being
attached more to the mother than the
father.

Freud believed that the boys of the fear

that father will retaliate against these
sexual impulses by castrating him.
Freud labeled it as” Castration Anxiety.”

The character observed in females is

called “ Electra Complex”.
Where the young girl child develops an
attraction towards the father.
 Latency stage:-
Occurs between the age of 6-12
years and is a period of
consolidation

Their attention turns to the skills

needed for copying with the
environment

The superego becomes firmly

internalized.
Genital stage:-
This stage begins with puberty
and is characterized by
reopening of the ego’s
struggle to gain mastery and
control over the impulses of id
and superego.
Fluctuating extremes in emotional behavior and preoccupation
with philosophical and abstract thoughts predominate due to
the struggle to attain a firm sense of self.
DEVELOPMENTAL TASKS
THEORY BY erik erikson:-
Erikson was of the view that freud
overemphasized the biological and sexual
determinants of developmental change and
underemphasized the importance of child rearing
experiences, social relationship and culture
influences on the development of ego or self.
 There are many different stages according
to this theory are:-
1) Trust versus mistrust.

2) Autonomy verses shame,

doubt.

3) Initiative versus guilt.

4)Industry versus inferiority.

5)Identify versus role

confusion.
TRUST VERSUS
MISTRUST:-
The major concern of this stage is the establishment of trust.

Infants develop trust when their world is consistent and

predictable i.e., when they are fed, warmed and comforted in a
consistent manner.
This stage can be equated with the “oral
stage of freud”.
AUTONOMY VERSUS
SHAME, DOUBT:-
This is during the toddler period when
children begin to assert independence.
Erikson believed that it was important to
give children a sense of autonomy.

Parents who shame their children for

misbehavior could create basic doubt
about being independent.
Initiative versus guilt:-
The child at this stage begins to
be task oriented and plans new
activities.

However the child may develop

excessive guilt about the act that
are initiated.
 INDUSTRY VERSUS
INFERIORITY:-

When the children enter the school, they

begins to perform tasks and acquire skills.

Achievements and the sense of competence

become important.
A child has no particular competences or who experiences
repeated failures might develop strong feelings of inferiority.
Identity versus role confusions:-

The major conflict during

adolescence is one’s role and
identity in a society.

The failure to solve this conflict

can result in role confusion or
diffusion in society.
The psychodynamic approach to personality development was
often criticized due to the lack of research support and the use
of a medical or disease oriented model for explanation.
This led to the development of behavior
learning theories.
 BEHAVIOUR LEARNING THEORIES
Based on the philosophy that learning is the key to the development of the behaviour
and not merely instinctive needs
 CLASSICAL CONDITIONING THEORY
BY IVAN PAVLOV
Two events observed to occur together
would tend to be associated or paired
together by observer. Through such a
pairing , the control of the response
reflex can be shifted from one stimulus
to another such that eventually a neutral
stimulus will elicit the response reflex.
• an application of this theory into a
dental situation is the example of a
young child entering a dental clinic,
being presented with a stimulus like
sound of a handpiece, this might evoke
an unconditioned response of anxiety in
the patient the initial stimulus of sound
of the handpiece when presented with
the site of the dentist will also bring
about the unconditioned response of
anxiety
 THEORY OF OPERANT CONDITIONING BY B.F. SKINNER

•  The main concept of this theory is that an Individual

learns to produce a voluntary response where the
consequences or the outcome are instrumental in
bringing about the recurrence of the stimulus. The
individual's response is changed as a result of previous
responses.

• Operant conditioning is classified into four contingency

arrangements like: positive reinforcements negative
reinforcements, punishment and response cost or time
out
 1. Positive reinforcement: occurs when a behavior, good or bad is
followed by a rewarding event. Many a times, just praising a patient
for maintaining his oral hygiene properly can stimulate him to
continue his meticulous oral hygiene behavior at home.
 2. Negative reinforcement: occurs when a behavior is followed by
the termination of an aversive event, thus increasing the likelihood
of the behavior. On the other hand, punishment and time out reduce
the likelihood of the behavior's recurrence.
 3. Punishment: exists when a behavior is followed by the onset of
an aversive event.
 4. Time out or response cost: refers to a behavior being followed
by the termination of a positive event.
 THEORY OF COGNITIVE DEVELOPMENT BY JEAN PIAGET

The word "cognitive" refers

to elements of perception,
awareness, judgement and
the ability to comprehend
empirical knowledge.
Accommodation-the individual's tendency to change in
response to environmental demands.

As a result of this new knowledge, the child is

temporarily in a state of "equilibrium" or cognitive
harmony.

The process of establishing equilibrium is known as

equilibration.

The processes of assimilation, accommodation and

equilibration function through out life as one adapts
one’s behavior and ideas to changing circumstances.
1. Sensorimotor stage (0-18 months)

• Intelligence is manifested in action.

• automatic inborn reflexes seen - ability to suck, cry move their

arms and legs, track a moving object and orient to a sound.

• Then the co-ordination of these reflexes improves.

• By the end of the sensorimotor stage, the child will have

transformed himself or herself from an organism totally
dependent on reflex and other hereditary equipment to a person
capable of symbolic thought.
2. Preoperational stage (18 months to 7 years) The essential characteristic of this stage is
imitation and the child pretend plays using his imagination.

3. Concrete operational stage (7 to 12 years) Children at this stage understand certain basic
logical rules and are therefore able to reason logically and quantitatively in ways that were not
evident in preoperational stage.. The child is also able to arrange objects according to some
quantified dimensions such as weight or size.

4. Formal operational stage (12 years onwards)

At this stage, the individual uses wider variety of cognitive opera and strategies in reasoning and
solving problems. The individual is highly versatile and flexible thought and reasoning and can see
things from a number of perspectives or points of view.
Frankl et al in 1962 introduced a behavioral rating scale, which
was modified by Wright in 1975 and is as follows:
1. Rating No. 1: Definitely negative
Refuses treatment
Cries forcefully
Is extremely negative, associated with fear
2. Rating No. 2: Negative
Is reluctant to accept treatment
Displays slight negativism
3. Rating No. 3: Positive
Accepts treatment with tense co-operative whining or timid behavior.
4. Rating No. 4: Definitely positive
Looks forward to and understands the importance of good preventive
care.
 SOCIAL LEARNING THEORY BY ALBERT
BANDURA
In the social learning theory, reinforcement is considered a facilitative
rather than a necessary condition for learning. Behavior is motivated
largely by our social needs. Reinforcement serve to regulate the
behavior but are relatively inefficient methods for learning behaviors.
The concepts of modelling and vicarious reinforcements are essential
components of this theory. Modelling is imitation through
observational learning or the learning and performance of a behavior as
a consequence of observing another person. Modelling is governed by
the attention of the observer, retention of the act mentally, motoric
reproduction of the act and reinforcement and motivation. Vicarious
reinforcement results in the change of the 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.
BEHAVIOR MANAGEMENT
What is Behaviour Management?
Behaviour management is as much an art form, as it is a science. It is not a
mere application of individual technique formulated to deal with individuals
but rather a comprehensive methodology meant to build a relationship
between the patient and the dental professional which ultimately builds trust
and relieves fear and anxiety.
Since childhood experiences play an important role in forming adult
behaviour, proper behaviour management right from an early stage will help
in development of a proper oral health attitude.
Wright in 1975 defined behaviour management as “ the
means by which the dental health team effectively and
efficiently performs treatment for a child and at the
time instills a positive dental attitude”
COMMUNICATIVE MANAGEMENT
•Communicative management is used universally for both the cooperative
and uncooperative child.
•It comprise of a host of communication techniques which when integrated
together ,enhances the evolution of a complaint and relaxed patient.
•It is an ongoing subjective process rather than a singular technique and is
often an extension of the personality of the dentist.
•Since these comprise the elements of usual and customary
communication, they are appropriate for all patients. In addition ,no
specific consent or documentation is necessary prior to use.
 The specific techniques associated with this process are :

 Voice control
 Non verbal communication
 Tell-show-do
 Modelling
 positive reinforcement
 Systemic desensitisation
 Distraction
 Parental presence/absence
 HOME
 VOICE CONTROL
Voice control is a controlled alteration of voice
volume, tone, or pace to influence and direct the
patient behaviour.
 Objectives of voice control

• To gain the patients'

attention and
compliance.
• To avert negative or
avoidance behaviour
• To establish
appropriate adult-
child roles
 NON VERBAL COMMUNICATION
Non verbal communication is the
reinforcement and guidance of
behaviour through appropriate
contact, posture, and facial
expression
 Objectives of nonverbal communication

1.to enhance the effectiveness of other communicative

management techniques

2.to gain or maintain the patient’s attention and compliance

 TELL SHOW -DO
• Addleston in 1959 introduced
the concept ‘tell-show-do’ as a
behaviour modification procedure
to introduce children to dental
equipment and procedures
• The tell show do technique is
used with communication skills
(verbal and nonverbal) and
positive reinforcement
 The technique involves verbal explanations of procedures in phrases
appropriate to the developmental level of the patient(TELL)
 demonstrations for the patient of the visual, auditory olfactory and
tactile aspects of the procedure in a carefully defined, non
threatening setting (SHOW)
And then without deviating from the explanation and demonstration
completion of the procedure (DO)
OBJECTIVES OF TELL SHOW DO

• To teach the patient important aspects of the

dental visit and familiarise the patient with
the dental settings
• To shape the patient’s response to procedures
through desensitisation and well described
expectations
 MODELLING
Bandura in 1969 developed a
behaviour modification technique
called “modelling” and “imitation”.
According to this technique learning
occurs only as a result of a direct
experience, which can be brought
about by witnessing the behaviour
and the outcome of that type of
behaviour of other people.
 There are four requirements for the modelling
technique they are:

1. Concentrated attention must be expended towards the

witnessing of the mode
2. There must be sufficient retention of desirable behaviour
in the absence of a model
3. One must be able ti reproduce effectively the behaviour
modelled
4. The newly acquired behaviour must be appropriately
rewarded to retain it
Modelling could be used to alleviate anxiety and encourage preventive care at
home. While observing a model undergo an examination or treatment, the patient
would gain information about the kinds of equipment that he or she will encounter
and it helps in reducing uncertainty. Modelling can be done using films or live
models.
REINFORCEMENT
The term reinforcement means, any consequence
which increases the likelihood of a behaviour being
shown. The reinforcer could be primary, based on
primary biological needs(e.g. food, water) or
secondary, which are things not intrinsically
rewarding(e.g. praise)
Another distinction is between positive and negative
reinforcers
 POSITIVE REINFORCEMENT
A “positive reinforcement” is a consequence which is
pleasant and increases the likelihood of behaviour when it is
effective technique to reward desired behaviours and thus
strengthen the recurrence of those behaviours.

social reinforcers include positive voice modulation, facial

expression, verbal praise, and appropriate physical
demonstrations and of affection by all members of the dental
team. Non social reinforcers include tokens and toys
NEGATIVE REINFORCEMENT
An unpleasant event that can be avoided through
some kind of action is called a “negative
reinforcement”. The threats of failing an examination
or being asked to leave a course of study are negative
reinforcers. A student may begin reading textbooks
and studying in order to avoid such circumstances
 SYSTEMIC DESENSITISATION
• Research carried out by Wople in 1952, led to the development of a
behaviour modification technique, called “systematic desensitisation”. This
technique is characterised by two elements, gradational exposure of the
child to his or her fear and induced state of incompatibility with his or her
fear
• The therapist creates a list of steps arranged as a hierarchy from the least to
the most stressful. The patient while in a state of deep relaxation exposed
one step at a time each step presented repeatedly until there is no evidence
of stress on the patient’s part. Thus the patient is desensitised to the
predominant fear.
 DISTRACTION
Distraction is a type of cognitive approach,
which is aimed at preventing any kind of
anxiety-provoking thoughts that heightens a
patient’s anxiety level.it is a technique of
diverting the patient’s attention from what may
be perceived as an unpleasant procedure. Since
the patient’s attention is drawn away, they are
less likely to dwell on anxiety
 OBJECTIVES OF DISTRACTION
1. To decrease the
perception of
unpleasantness

2. To avert negative or
avoidance behaviour
 PARENTAL PRESENCE / ABSENCE
communication between dentist
and child is paramount and that
this communication demands
focus on the part of both parties.
Children’s responses to their
parent’s presence or absence can
range from very beneficial to very
detrimental.
 HAND-OVER-MOUTH EXERCISE
(HOME)
HOME is an accepted technique for
intercepting and managing
demonstrably unsuitable behaviour that
cannot be modified by basic behaviour
management techniques. The
techniques is specifically used to
redirect inappropriate behaviour and re
establish effective communication
 METHOD
1. The dentist firmly but gently places his hand on the child’s mouth and whispers in his ear
that when he cooperates, the hand will be removed.
2. Maintenance of a patent airway is mandatory. Upon the child’s demonstration of self
control and more suitable behaviour, the hand is removed and the child is given positive
reinforcement. Communicative management techniques should then be used to alleviate
the child’s underlying fear and anxiety
4. The decision to use HOME must take into consideration,
- other alternate behavioural modalities
- patient’s dental needs
- the effect on the quality of dental care
- patient’s emotional development
- patient’s physical considerations
5. Written informed consent from a legal guardian must be obtained and documented in the
patient’s record prior to the use of HOME. The patient’s record should include informed
consent and indication for use.
OBJECTIVES
1. to redirect the child’s attention, enabling Communication with the dentist so that
appropriate behavioural expectations can be explained
2. To extinguish excessive avoidance behaviour and help the child regain self control
3. To ensure the child’s safety in the delivery of quality dental treatment
4. To reduce the need for sedation or general anesthesia
 INDICATIONS
A healthy child who is able to understand and cooperate, but who exhibits hysterical avoidance
behaviours

CONTRAINDICATIONS
1. In children who due to age, diability, medication, emotional immaturity are unable to verbaly
communicate, understand and cooperate
2. Any child with an airway obstruction
CONCLUSION

Behavioural science play a major role in understanding the individual,

his community and his environment. The desire to understand
behaviour and help maintain people at an almost perfect state of oral
health rather than wait to treat them after they have developed oral or
dental disease has been at the forefront of promoting a healthy lifestyle
and modifying habits do as to reach optimal oral health status.
REFRENCE

ESSENTIALS OF PUBLIC HEALTH DENTISTRY

PETER SOBEN
6TH EDITION

IMAGE CURTESY- GOOGLE IMAGES

SHOBHA TANDON – PEDIATRIC DENTISTRY
(3RD EDITION)