Psychological management of child in dentistry using Jean Piagets Cognitive Theory

Psychological management of child using Jean Piaget’s Cognitive theory

WHY CHILD PSYCHOLOGY

“Although the operative dentistry may be perfect the appointment is a failure if the child departs in tears” - Mc Elroy (1895)

• Child psychology is the heart and soul of paediatric dentistry as it is directly related to dental fear, the primitive response present universally.

• Dental setup is always considered as a threat either due to objective or subjective conditioning of patients towards dentistry and dental pain being one of the worst pains of human kind makes the matter worse.

• Invasive procedures like injections aggravate the fear. Despite all the behaviour management techniques available there is dearth of a sincere effort from the dentist’s side to understand a child’s perspective about the dental appointment.

• It’s very important because the dentist is handling a cognitively, physically mentally and emotionally maturing child

• To lay the foundation of grooming the child in to a perfect patient with positive attitude towards dentistry on the whole

What's the hurdle for practice.

flight or fight One has to realise it is either a fright or a flight situation to the child as most

of the time he is not prepared to face the treatment and does not realise the need for the treatment.

Eventually the irony the child is graded by the dentist as definitely negative and posted to general anaesthesia, which is not free of side effects.

The child is compromised due to the lack of knowledge of dentist on child psychology……. So we end up doing General Anesthesia

"Don't become a mere recorder of facts, but try to penetrate the mystery of their origin." Ivan Pavlov  

(1849-1936)

Cognitive development of child• Cognition refers to mental activities involved in acquisition,

processing, organisation and use of knowledge. • This includes detecting, interpreting, classifying and

remembering information, evaluating ideas, inferring principles, reducing rules, imagining possibilities, generating strategies, fantasizing and dreaming

"The brain is wider than the sky." Emily Dickinson (1830-1886)

Cognitive theory• Cognition refers to mental activities involved

inacquistion, processing, organisation and use of knowledge.

• Cognition include detecting ,interpreting, classifying and remembering information, evaluating ideas, inferring principles and reducing rules, imagining possibilities, generating strategies, fantasying and dreaming.

COGNITIVE THEORY - JEAN PIAGET (1952)

Processes of cognition

Developing a mental schemata–child take in new experiences through their own system of knowledge.

It is now known that infants can from the first day of life smell, see, and hear.

Even very young infants have the ability of perceiving movement, facial relationships, and colour.

Cognitive competence explains how and why an infant explores a nursing mother’s fingers

ASSIMILATION

MODIFYING ONE’S ENVIRONMENT

• Complementary process for intelligence to develop child goes on adding newer information to the original schemata

ACCOMMODATION

MODIFYING SCHEMA

EQUILIBRATION• Changing basic assumption

following adjustments in assimilated knowledge

Equilibration : A balanced , harmonious relationship between one’s cognitive structures & the environment.

In 1984 , Mussen and co workers noted that there are 4 major areas of cognitive development

1. Area of Perception

2. Recognition of Information

3. Ability to Categorize

4.Enhancement of memory

1. AREA OF PERCEPTION

Every young infant have the ability to perceive, movement facial

relationship and color .2. RECOGNITION OF INFORMATION

The child's schemes contain some but not all the crucial elements of the object. So it recognizes the schema even with few information recollected. 3. ABILITY TO CATEGORIZEChildren can group things together by way of their shape, color, and use even by the age of 1 year. Cognitive growth is mainly influenced by the intellectual stimulation he gets from his surrounding environment.

4.ENHANCEMENT OF MEMORY

Even very young infant have the ability to recall past events and use the information gained to help them to form a reaction to things presently going on

SENSORIMOTOR STAGE

Inborn motor and sensory

reflex

Primary circular reaction

Secondary circular reaction

Tertiary circular reaction

through active experimentatio

n / Causality

Object permanence and insight

Piaget described that child develop knowledge in the

following stages:

CIRCULAR REACTIONS Primary circular reaction(1-4months)

Learning through already known object describes recreating an already known satisfying action, such as thumb sucking.

Secondary circular reactions 4-8 months

• Recreating of an accidentally discovered cause and effect.

• Responds to own name

TERTIARY CIRCULAR REACTIONS 12-18 MONTHS

Deliberately varies behaviour to create novel effect. Reactions involve

experimentation

OBJECT PERMANENCE Objects continue to exist even when they are not perceivable by the child.

Clinical implications of Sensorimotor stage

• The dental home concept says treat the child as soon as the first tooth erupts in the oral cavity ie at 6 months so if the mother brings the child very frequently along with her the child learns about the setup and gets to feed information in brain through circular reactions also the stranger anxiety which peaks if not seen the stranger can be minimised.

• This can be done by taking advantages of exemplary modeling by mother or sibling in procedures like scaling done on them.

• Those being treated should display courage and smile throughout the procedure, giving an impression to the child that dentistry is not a place of threat instead can be enjoyable, as cognitive growth is mainly influenced by the intellectual stimulation he gets from his surrounding environment.

• So, appropriate conduct of pediatric dentists is extremely important during the treatment of children in situations that can lead to fear, helping to avoid dental fear and contributing to improvements in health care promotion.

PRE OPERATIONAL STAGE

• Preschool children are considered as not having acquired the cognitive ability to think logically

• Acquire the ability to form mental images of objects and events

• Language develops to the point at which they begin to think in terms of verbal symbols – words.

PRE OPERATIONAL PERIOD

PRE CONCEPTUAL

2-4yrs

INTUITIVE

4-7yrs

ALL FEATURES

• Trial and error• Animism• Egocentrism• Centration• Generalization• Constructivism

TRIAL AND ERROR• The child understands himself and his

surrounding environment by becoming a little explorer, seizing opportunities for picking and dropping, poking and rubbing, twisting and pulling, shaking and breaking.

• The child attains his normal intellectual growth due to these explorations.

• Is the belief that inanimate objects are capable of actions and have lifelike qualities.

• Ex, a child who gets hit by the edge of the door while running says that the door has gone mad and hit him badly.

• Essentially everything is seen as being alive by the child, so stories that have inanimate objects with life are acceptable.

• Animism can be used to dentist's advantage by giving life-like names and qualities to equipments, e.g. the handpiece is the "Whistling Willie" who is happy and sings while he polishes the child's teeth

ANIMISM

Using fantasy play and language to help child become more comfortable

Tooth brushingWashing the mouth with vaccum and 3

way syringe

Cleaning the teeth with brush in hand

piece

Drilling a vital tooth with air

turbine

Anesthetic solution referred As water to put tooth to sleep

Motivating patient towards oral health

Structuring

Constructivism • Children are

active thinkers who are constantly trying to construct more accurate or advanced understanding of the world around them

Constructs knowledge about unknown world of dentistry by handling and working with dental instruments

Egocentrism• Child is incapable of assuming another person's point of view. • Instead refers to intellectual limitation.

Types of Egocentris

m

Perceptional Cognitive

Cognitive egocentrism

• Children find it difficult that other people do not know their thoughts. In communicating with

others children often forget themselves in the role of listener and to adapt their message to that

person.

To assess the concept of cardinal numbers, the coin experiment is done• Pre operational child-longer row has more coins• Concrete operational – rearrangement of button

does not change their number

Perceptual egocentrism• Incapable of assuming another persons point

of view

Reasoning

• They are capable of transductive reasoning from particular to particular. They can understand cause-effect relationship but is limited to a particular event or object.

• They are NOT capable of inductive reasoning (from particular to general) or deductive reasoning (from general to particular).

• As result a volley of questions may be asked to the adult such as "How" and "Why".

Generalization: e.g. all that flies are assumed as birds

Clinical implication of egocentrism• It will be useless to point out how proud his parents will be if he cooperated

for the dental treatment as the child can't see the parent's point of view. • Instead if the dentist shows the decayed discoloured teeth and says "your

teeth will be better if these germs are out of them" it is accepted by the child.

• This is structuring, a procedure of behavior management, where the child is explained the need for the procedure with proof.

• An Early childhood caries patient is given a face mirror and explained that all anterior teeth are broken and they need to be repaired to look like his friends, make the child realize the need for treatment and he will cooperate through out.

• Also allowing him to watch what is done and witnessing improvement in the appearance of decayed teeth will form a foundation for future procedures

Period of Concrete Operations. (6-12 years)

• An improved ability to reason emerges during this period.

• The thinking process becomes logical.

• He develops the ability to use complex mental operations such as additions and subtraction

• The child is able to understand others point of view and animism declines.

FEATURES• Conservation• Decentration• Elimination of egocentrism• Seriation• Transitivity• Reversibility

Decentration: • To focus their attention on several attributes

of an object or event simultaneously & to understand the relation between dimensions.

Conservation :• Understanding that quantity, length or no.

of items is unrelated to the arrangement or appearance of the object or items. the child can successfully pass through the conservative experiments.

Seriation:• A characteristic of the concrete operational child is

the ability to arrange objects according to some quantified dimensions such as weight or size. This ability is called Seriation.

• An 8 year old can arrange eight sticks of different lengths in order from shortest to longest

Transitivity :There are certain fixed relations among the qualities of objects.

Elimination of egocentrism

• Develops the ability to see the things from another’s perspective.

• Animism declines.

REVERSIBILITY

The child understands that numbers or objects can be changed then returned to their original state.

For this reason child will be able to rapidly determine that if 4+4 equals 8, 8-4 will equal 4 , the original quantity.

Clinical implication• During dental treatment, instructions

should be based on concrete objects. " Brush your teeth in up and down strokes for front teeth; back and forth strokes for back teeth, twice a day" may be less understood than saying and demonstrating" This a model of your teeth.

• The brush should be held in this way for front teeth and moved in up and down direction, in this manner."

Clinical implication of Concrete Operational stage

Period of Formal Operations (11 – Adolescence)

• At this stage, the child's thought process has become similar to that of an adult, and the child is capable of understanding concepts like health, disease, and preventive treatment.

• He will begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations.

• Adolescent egocentrism can be dissected into two types of social thinking, imaginary audience and personal fable.

• This makes them susceptible to peer influence but, in the latter adolescents sense of personal uniqueness and invincibility makes them think "because I am unique, I am not subject to consequences others will experience”.

Period of Formal Operations: 11-18 Years

• In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations.

• During this stage the young adult is able to understand such things as love, "shades of gray", logical proofs and values. The young adult begins to entertain possibilities for the future and is fascinated with what they can be. The adolescent's thought process is similar to adults and can understand concepts like health, disease and prevention. Hence he should be treated like an adult.

Adolescent EgocentrismCan be dissected into two types of social thinking: • Imaginary audience involves attention

getting behaviour and heightened self-consciousness. This makes them susceptible to peer influence.

• Personal fable: Adolescents sense of personal uniqueness and invincibility which makes them think "because I am unique, I am not subject to consequences other will experience".

• The imaginary audience refers to an egocentric state where an individual imagines and believes that multitudes of people are enthusiastically listening to him or her at all times.

• In extreme cases, belief in an imaginary audience can lead to paranoia as the sufferer believes he or she is being watched by an invisible audience at all times.

• Fearing that he or she is being observed and evaluated, such an individual may develop a phobia of making mistakes or looking foolish in public.

Personal fable

• PF may make the patient ignore threats to health like decalcification of teeth from poor oral hygiene.

• They think- others may have to worry about, but I don’t