01 - Psychosocial Development

Preschool children

Learning Objectives

Understanding psychosocial development is critically important if you want to be able to communicate effectively with your child patients. You might also need to call on an understanding of developmental psychology when treating adults whose psychosocial development didn’t progress all the way to normal adult interaction.

In addition to viewing this program, read pages 50-65 in Contemporary Orthodontics, 5th ed. (58-70 in 4th ed.) and take the self-test. Be sure you are able to:

• describe Erickson’s stages of socio-emotional development and discuss how children’s needs at each stage relate to their dental treatment
• describe each of Paiget’s stages of cognitive development and show how they relate to dental treatment
• discuss the basic principles of learning theory in terms of classical conditioning, operant conditioning, and modeling
• relate each type of learning to communicating with and modifying the behavior of a child or adolescent patient
• discuss how children’s self-concepts influence their personality development
• apply the concepts of psychosocial development in post-adolescent and adult life to communication with parents about how to influence their children’s cooperation with dental treatment.

Classical Conditioning in Young Children

Although the basic mechanisms of learning appear to be the same at any age, psychologists generally consider that there are three distinct mechanisms by which behavioral responses are learned: (1) classical conditioning, (2) operant conditioning, and (3) observational learning. All are highly important in dealing with preschool children.

Classical conditioning operates by the simple process of association of one stimulus with another, and for this reason sometimes is referred to as “learning by association”. It occurs readily with young children and can have a considerable impact on a young child’s behavior on the first visit to a dental office. By that time it is likely that the child will have had considerable experience with pediatricians and other medical personnel who did something that was painful or unpleasant. The reflex reaction to pain is crying and withdrawal.

If the “unconditioned stimulus” of pain becomes associated with the appearance of people in white uniforms or white coats, the mere sight of a white coat (“conditional stimulus”) can become enough to produce the reflex behavior associated with pain. Further, associations of this type can become generalized, so that the atmosphere of the doctor’s waiting room may produce crying and withdrawal after unpleasant experiences in a room like that.

Classical Conditioning: Reinforcement

The association between a conditioned and an unconditioned stimulus is reinforced (strengthened) every time they occur together. Every time a child has something unpleasant happen when he or she is taken to a typical doctor’s office, the association between pain and the atmosphere of that office is reinforced. The child becomes more and more sure that bad things happen in a place like that.

As this figure illustrates, if injections that hurt are only given by someone in a white coat, the sight of a white coat will become more and more likely to elicit a negative response.

Loss of Conditioning

Because of the association between the physician’s office and the dental office, behavior management with young children in the dental office is easier if the dental office looks as little like the typical physician’s office or hospital clinic as possible. It helps to reduce children’s anxiety and crying / withdrawal if the dentist and his / her staff look different and if the experience on the first visit to the dentist’s office is different. If possible, nothing painful should be done on the child’s first visit.

The opposite of generalization of a conditioned stimulus is discrimination. If a child is taken into other office settings that are different from those where painful things happen (for instance, a dental office where painful injections are not necessary), a discrimination between the two types of office will develop, and the conditioned response to the dentist’s office will gradually be extinguished.

Observational Learning: Early Stages

Another important way in which young children acquire behavior is by imitating behavior they observe. Although this type of learning is quite compatible with conditioning, it is a different way of learning. Much of a child’s behavior in a dental office is learned from observing siblings, other children or parents.

There are two stages in observational learning: acquisition of the behavior by observing it, and performance of the behavior. Children are capable of acquiring almost any behavior that they observe closely if it is not too complex for their stage of physical development.

Whether a child actually performs an acquired behavior depends on several things. For preschool children, the most important is the characteristics of the role model. If the role model is liked or respected, the child is more likely to imitate him or her. Especially for older children, the observed consequences of the behavior are important. A child is more likely to perform a behavior if she observed that this behavior was rewarded rather than punished.

For a child, an older sibling or parent is often the object of imitation. Observing how an older sibling is being treated (one who behaves well and is rewarded!) is important in learning how you should behave when it’s your turn. The mother’s attitude and behavior when her child visits the dentist will influence the child’s behavior—a calm and reassuring mother is a key to calm acceptance of treatment by a child. And of course that goes for father as well if he brings the child to the dentist.

Early Emotional Development: Stage 1

Emotional development proceeds through distinct stages, which have been described in detail by Erickson. In Erickson’s view, each developmental stage represents a “psychosocial crisis” in which the individual is forced toward one or the other extreme outcomes of that stage. Although the stages occur at different times for different individuals, their sequence is constant—but some qualities of earlier stages may be seen later because they were not completely resolved when they should have been.

The first stage, from birth to 18 months, is “Development of Basic Trust”. The extremes are basic trust or basic mistrust. Successful development of trust depends on a caring mother or mother substitute who meets the emotional needs of the infant. A strong bond between the parent and child must be maintained to allow the child to develop basic trust. As we have noted in an earlier module, physical growth can be significantly retarded if the child’s emotional needs are not met by appropriate mothering.

The tight bond between parent and child is reflected in “separation anxiety” when the child is separated from the parent. If dental treatment is required during this first stage, it is preferable to have the mother present. At later ages, a child who never developed a sense of basic trust will have difficulty in situations that require trust and confidence in another person, is likely to be frightened in unusual settings like a dental office, and will require special efforts to accept dental treatment and trust the dentist and staff.

Early Emotional Development: Stage 2

The second stage in emotional development, from 18 months to 3 years, is “Development of Autonomy”. At this stage the child is moving away from the mother and developing a sense of individual identity or autonomy. This is the “terrible twos”, in which a child sometimes says no to every wish of the parents, insists on having his own way, and sometimes retreats to dependence. The child needs to be protected from the consequences of dangerous and unacceptable behavior while being given opportunities to develop independent behavior. Consistently enforced limits on behavior at this stage lead to further trust in a predictable environment.

Failure to develop a proper sense of autonomy leads to doubts in the child’s mind about his ability to stand alone, and that leads to doubts about others. The resulting state is one of shame, a feeling of having all one’s weaknesses exposed, and a consistent defensive and mistrustful attitude.

Emotional Development: Stage 3

The third stage, from age 3 to 6 years, is “Development of Initiative”. In this stage, further development of autonomy is accompanied by extreme curiosity and questioning. The child is very teachable, and eagerly models behavior by those he respects—but also is very sensitive to reproach.

The child’s ultimate ability to initiate new ideas or activities is thought to depend on how well he manages at this stage to express new thoughts without being made to feel guilty about it.

Early Cognitive (Intellectual) Development: Stage 1

Cognitive development also occurs in a series of relatively distinct stages. These can be considered an excellent example of biologic adaptation to the physical and sociocultural environment in which the individual must live. To the Swiss psychologist Piaget, adaptation occurs through assimilation and accommodation. In this process the child incorporates or assimilates events into mental categories called “cognitive structures”, which are classifications for sensations and perceptions. In the complementary process of accommodation, the cognitive structure is modified to better represent the environment. Intelligence develops as an interplay between assimilation and accommodation.

From this perspective there are four cognitive developmental stages. A child’s way of thinking is quite different at the different stages. Intellectually he or she is not a little adult. A child doesn’t think like an adult until the final stage.

The first stage, from birth to 2 years, is called the sensorimotor period. During this stage the child develops the concept of objects as being things that are permanent rather than disappearing when the child is not looking at them. The foundation for language development is laid, but communication with adults is limited because of the limited language capability.

Early Cognitive (Intellectual) Development: Stage 2

The second stage of cognitive development, from age 2 to 7 years, is the “preoperational period”. During this stage, a child develops the capacity to form mental symbols representing things and events that are not present and learns to use words to symbolize these absent objects. But, a child at this stage often understands words quite differently from adults.

A prominent part of thought processes at this age is the literal or concrete nature of the language. The child understands the world in the way he or she experiences it. Concepts like time and health that cannot be sensed directly are very difficult for a child at this stage to understand.

Important characteristics of thought processes at this stage are (1) egocentrism, which means that the child cannot assume another person’s point of view. His own perspective is all he can manage at this stage; and (2) animism, investing inanimate objects with life. Stories in which improbable things come to life are quite acceptable at this stage. Even parts of the child’s own body can seem to take on a life of their own—something that the dentist can take advantage, for instance in helping a child keep “Mr. Thumb” from getting in his mouth so much.

Communication with Young Children: Infants

Based on these concepts of psychosocial development, how would you approach the problem of communicating with preschool children in a dental treatment setting?

It is unusual for dentists to work with infants, but if this is necessary, remember the importance of separation anxiety in this age group:

• having the mother (or father if he is the primary caregiver) present is important, and it is advantageous to have the parent holding the child
• the parent’s attitude is important—if she or he is calm, the infant likely also will be, and if the parent is anxious and upset, the infant will pick up on that as well.

Communication with Young Children: First Dental Visit

A child’s first dental appointment often is between ages 3 and 6. This is the time period during which the associations in classical conditioning are being learned, autonomy is developing, and the child intellectually is in the preoperational period that is characterized by egocentrism and animism.

The first important communication is non-verbal. It is made by what the dental office, dentist and staff look like. A new patient age 3 or 4 almost surely has already been to a pediatrician, probably on multiple occasions, and may have found this an unpleasant experience. The child’s behavior is likely to be better if the dental office does not trigger a conditioned response based on expectation of a similar unpleasant experience.

These pictures of a modern pediatric dentistry / orthodontic office (in which a pediatric dentist and orthodontist practice together) reflect an effort to differentiate this treatment setting from a medical one.

Image 1: The view from the office door, entering the pediatric dentistry / orthodontic practice.	Image 2: Looking past the toward the treatment area.
Image 3: The orthodontist at the front desk, wearing a gown unlikely to be confused with one encountered at a hospital clinic.	Image 4: Staff at the front desk. Note the jackets worn by the staff.

Communication with Young Children: Autonomy and Observational Learning

How do you deal with a 2- or 3-year old child who is likely to reject almost any suggestion and is determined to have things his own way? Separation anxiety still must be considered, and having the mother present can be helpful. In addition, it is very helpful to arrange things so that the child has choices and is led to think that he or she chose to do whatever is required rather than being forced to do it. Offering choices to the child—would you like to ride up in this chair, or would you rather jump up there after it goes up? would you like a green napkin or a yellow one?—can help in dealing with this search for autonomy.

In the age 4-6 group, a child is likely to be intensely curious about the dentist’s office and what goes on there. An exploratory visit with the mother present and little or no treatment usually helps the dentist get off to a good start. After that, the child’s degree of independence must be considered. A child at this stage usually tolerates being separated from the mother and may behave better if she is not present, so that independence rather than dependence is reinforced—but with some children at this age, having the mother present can be helpful, and it’s OK to ask for her help (image 1).

Both of these age groups learn from observational modeling, so allowing a younger child to observe an older one calmly receiving dental treatment greatly increases the chance he will behave in the same calm way when it’s his turn (image 2). In both pediatric dentistry and orthodontics, an open treatment area is preferred, because it facilitates observational learning (image 3).

Image 1: For this 6-year-old, having mother present in the treatment room during an initial examination was important reassurance. Making parents welcome in the treatment room, in the right circumstances, can make treatment go more smoothly.	Image 2: As his sister is being examined by the pediatric dentist, this boy is enjoying the play area in the corner of the treatment room, and noting silently how she is behaving (very well).
Image 3: In pediatric dentistry and orthodontics, an open treatment area is preferred because it facilitates observational learning.

Communication with Young Children: Age 4-6

Intellectually, a 4- to 6-year old preschool child uses language in a very literal sense and understands words only in the context in which they were learned. He or she is not able to comprehend complex language or concepts that are outside direct experience with the world. Nor can such a child assume another’s point of view.

For this reason, the dentist and dental staff should use immediate sensations instead of abstract reasoning in discussing concepts like prevention of dental disease. The child can understand and relate to “Brushing your teeth makes them feel clean and smooth”, but not to “Brushing your teeth will prevent tooth decay”. It does no good to tell the child how proud the parents will be if he brushes his teeth well. Assuming the parents’ point of view and imagining how they will feel is beyond the mental capacity of a child of this age. Egocentrism, focusing on your own point of view, is a characteristic of this age group.

Animism, another major characteristic at this age, can be used to the dentists’ advantage in communicating with the child. The dental handpiece is friendlier if it becomes “Whistling Willie” rather than a cutting instrument, and other dental instruments are more acceptable if named similarly. As we have noted already, if Mr. Thumb is a problem because he gets into the child’s mouth, it’s better for the dentist and the child to form a partnership to keep Mr. Thumb out rather than telling the child to stop sucking his thumb.

Elementary school children

Operant Conditioning

For children in the late preschool and elementary school age groups, operant conditioning—an extension of classical conditioning that is the basis of most behavior in the view of Skinner and his followers—is an important aspect of communication. Skinner described four types of operant conditioning. The first of these is positive reinforcement (images 1, 2, 3). If a pleasant consequence follows a response, the response has been positively reinforced, and the behavior that led to this response is more likely in the future. Providing a reward to a child who has behaved well on a dental visit is positive reinforcement (and can be effective in preschool children as well as older ones).

A second type of operant conditioning, negative reinforcement, also increases the likelihood of a response in the future. This created by the withdrawal of a stimulus that was unpleasant. If a child who didn’t want to go to the dentist throws a temper tantrum and escapes having to go because of this, the chance the same thing will happen next time increases because the behavior has been reinforced. In dental practice, it is important to positively reinforce only desired behavior, and equally important not to reinforce undesirable behavior.

Image 1: Operant conditioning that increases the probability of a response	Image 2: Positive reinforcement of a child: he is receiving a “terrific patient” button after his visit to the dentist
Image 3: Kaitlyn’s reward for doing well in her appointment is to choose her own gift from the collection in the cabinet as she leaves the treatment room.

Operant Conditioning (cont.)

The other two types of operant conditioning decrease the likelihood of a response (image 1). The third type, omission, (also called time out) involves removal of a pleasant stimulus after an undesired response. You probably remember being sent to your room to stay alone until you could come back and play properly with whatever toy you were abusing.

The fourth type of operant conditioning, punishment, occurs when an unpleasant stimulus follows undesired behavior. Like the other forms of operant conditioning, this is effective in older as well as younger individuals.

As a general rule, reinforcement that increases the likelihood of a response is more useful in the dental office than omission or punishment, with positive reinforcement being the major method. One mild form of punishment that can be used with children is “voice control”. This involves speaking to the child in a firm voice to gain his (or her) attention, telling him that his behavior is unacceptable, and directing him (or her) how to behave. This method should be used with care. It is most effective when a warm and caring relationship with the dental team has been established, and the child should be immediately rewarded for an improvement in the behavior.

Emotional Development in Elementary School Children

Children between the ages of 7 and 11, in Erickson’s sequence of stages of emotional development, are at the fourth stage, “Mastery of Skills”. At this stage, the child is industriously acquiring the skills needed in a competitive world and learning the rules by which that world is organized. The influence of parents as role models decreases, and the influence of the peer group increases.

The positive side of this stage of development is a sense of successful accomplishment and confidence. The negative side can be a sense of inferiority. It is necessary to accept that one cannot be the best at everything, but failure to measure up to the peer group can lead to personality characteristics of inadequacy, inferiority, and uselessness. The child needs to be in an environment in which there is a reasonable chance that challenges will be successfully met, rather than one in which failure is all but guaranteed.

Cognitive Development in Elementary School Children

At ages 7-11 (approximately—remember that the sequence is consistent, but the precise age is not), a child enters what is called the “period of concrete operations”. At this stage, typically after preschool and first grade experiences, a child can use logical reasoning to deal with situations that he or she can observe directly (concrete situations) but still has limited ability to reason on an abstract level. The ability to see another point of view develops, while animism declines.

Although this brings the child closer to the way adults view the world, there still are major cognitive differences. Ideas presented as abstract concepts are not likely to be understood; ideas illustrated with concrete objects can be grasped successfully.

“Good oral hygiene is important to keep your mouth healthy” is far too abstract. “This is your toothbrush. Put toothpaste on it like this. Brush your teeth every morning and every evening, so your teeth and mouth will feel good” is much more likely to produce a positive result, especially if the child is positively reinforced for doing it successfully. In that respect, parental attitudes remain very important.

Communication with Elementary School Children

An elementary school child’s psychosocial development can be characterized as greatly influenced by operant conditioning, focused on acquiring academic and social skills while dealing with success versus failure, and largely limited to dealing with concrete objects rather than abstract ideas. As a dentist who will be treating children, how can you take advantage of knowing this to improve communication with a child at this stage?

As with younger children, positive reinforcement of desired behavior is an important part of doing this. Appropriate praise and rewards are highly effective in shaping how a child at this stage reacts to treatment situations—but of course rewarding undesired behavior should be avoided.

Because observational learning is so important, it is more effective to put children in an open treatment area where they have an opportunity to see what is happening with their peers, rather than using small private treatment rooms. At preschool and elementary school ages (and often later), Susie will benefit from observing Jane’s experience with the dentist and talking with her about it.

An early stage of orthodontic treatment often begins at this stage, and an open treatment area that allows observation and interaction with other patients is advantageous. Having parents present almost never is a good idea—the goal is to foster indendence, not dependence.

Image 1: Positive reinforcement in the form of selecting a reward from the pediatric dentist’s reward collection after a dental examination.	Image 2: An open treatment areas in the orthodontic office encourages observational learning

Communication with Elementary School Children (cont.)

Instructions on what the child should do between appointments must be presented concretely and simply, in a “show and tell” format. How to use a toothbrush is a primary example. So is how to use an orthodontic appliance, which at this stage often is a removable device of some type. Because the parents will be in a position to reinforce this behavior, the primary caregiver should be with the child when this is done.

With mother watching, the instructions for a removable appliance should be something like “This is your new aligner. Put it in like this, and take it out like this. Now show me you can do that. Good!” Or “No, that wasn’t quite right. Look again at how to do it. Now show me you can do it”. Then “Put it in right after dinner every evening, and wear it until the next morning. Brush it like this every morning with some dishwashing detergent to get it clean. After it’s clean you can brush it with toothpaste to make it taste better.”

If the appliance is to modify growth, explaining to mother in more detail why it’s important to put it right after dinner instead of waiting until bedtime, based on what we know about the timing of growth, also can be important—but the child isn’t going to grasp that at this stage of development.

Communication with Older Elementary School Children

In orthodontics, the same approach of concrete instructions is needed with children in the earlier elementary school years, but could be modified somewhat with those beyond age 11. The objective, of course, is to be sure the child (and parent) understand how the appliance is to be used, and what the goal of treatment is.

The detailed instructions and demonstration would be about the same for the somewhat older elementary school children, but the goal of treatment could be in more intellectual terms (for an 11-year-old it would be OK to talk about modifying growth, for instance). The parent could be called in after the presentation to the older child to let him or her show the parent how the appliance is to be used (while the doctor or an assistant watches, ready to offer praise or a gentle correction).

The steps in showing an 11-year-old girl her new headgear and how it is to be inserted and hooked up are shown in the attached images.

Image 1: The orthodontist is fitting a headgear for this 11-year-old child.	Image 2: Patient holding facebow of the headgear, preparaing to learn how to put in the attachments on her upper molar teeth.
Image 3: Inserting the facebow, following directions as she does so.	Image 4: Connecting the facebow to the neck strap, as the orthodontist offers specific, concrete instructions.
Image 5: The orthodontist is checking that the headgear is correct—and preparing to offer praise for managing it well, or provide further instruction if needed.

Adolescents

Emotional Development

The fifth stage in emotional development as outlined by Erickson, which occurs during adolescence (age 12 to 17) is “Development of Personal Identity” (image 1). This stage accompanies the major physical changes during adolescence and is complicated by the emergence of sexuality. During this time, physical ability and academic responsibilities increase, and career possibilities begin to be defined.

Development of identity includes both a feeling of belonging to a larger group and a realization that one can exist outside the family. This requires a partial withdrawal from the family, and the peer group becomes even more important as role models—but some separation from the peer group also is necessary in order to establish personal identity. An inability to separate from the group indicates failure to complete the establishment of identity. It results in a poor sense of direction for the future and confusion regarding one’s place in society (role confusion), all of which leads to low self-esteem.

Image 1, Stages of emotional development: In adolescence, belonging to a peer group while maintaining a place in the family structure is important—but establishing personal identity requires some separation from both.	Image 2: At adolescence, an individual encounters the stress of adapting to physical change and accepting all the decisions that will have to be made.

Adolescence: Cognitive Development

Most children enter the final stage of cognitive development, the “period of formal operations” at about age 11. At this stage the child’s thought processes have become similar to adults, and he or she should be treated as an adult. The child now can deal with abstractions and complex reasoning, and is aware that others also think in the same way—but in a new expression of egocentrism, each adolescent presumes that others are thinking about the same things he or she is, himself or herself. This leads to a feeling that one is being constantly observed and criticized by those around them, who become an “imaginary audience”.

This imaginary audience makes adolescents quite self-conscious and extremely susceptible to peer influence. They worry about what peers will think of their appearance and actions—without realizing that their peers are too concerned with themselves to be paying attention to much else. This idea that “others really care about my appearance and feelings as much as I do” leads adolescents to believe that they are unique, special individuals. Otherwise why would everyone else be so interested in them?

As a result, a “personal fable” tends to emerge. This says that “because I am unique, I am not subject to the consequences others will experience”. The personal fable is a powerful motivator in allowing one to cope with a dangerous world (“it’s OK to get on the plane, others may be killed in a plane crash but I won’t”) and is valuable from that perspective, but it also can lead to an underestimation of risk and dangerous risk-taking. Did you lose a high-school classmate to some accident caused by this attitude?

Communication with Adolescents

The imaginary audience and the personal fable can have a significant impact on whether an adolescent accepts dental / orthodontic treatment, and the extent to which he or she cooperates with treatment. An adolescent may complain, for example, that wearing rubber bands during the day, makes him look funny to his friends. Telling him that everybody does it so he should too is unlikely to be accepted. A better approach, which does not deny his point of view, is say that his friends may react that way, but ask him to try it for a specific time and judge their reaction. A test of his perceived reality usually demonstrates that the audience does not react negatively, or that he can cope with it.

The personal fable has the same element of ignoring risk related to treatment as to other things. Sometimes an adolescent simply ignores the chance of decalcification of teeth around an orthodontic appliance if he or she does not maintain good dental hygiene. The attitude, of course, is “Others may have to worry about that but I don’t”. Showing him or her the beginning of problems (“you’re starting to get scars on your teeth”) may be the only way to get a positive response.

It is particularly unfortunate if orthodontic treatment becomes the focus of an adolescent’s struggle to become independent of the parents. If parents force a reluctant adolescent into treatment, he or she may not cooperate as a demonstration of independence—so it is good judgment not to start treatment until the adolescent wants it. By the same token, an adolescent who really wants treatment and has difficulty in convincing the parents to provide it, is likely to be a highly cooperative patient.

Older Patients and Parents

Psychosocial Maturation

The first step into adult emotional development, as described by Erickson, is the “Development of Intimacy” in young adults, where the contrasts are Intimacy vs Isolation.

The development of intimacy refers to the establishment of affiliations and partnerships with both the opposite sex and others of the same sex, to allow progress toward achieving career goals. This requires a willingness to compromise and even sacrifice some things in order to attain others. Failure leads to social isolation, strong prejudices, and attitudes that keep others away.

When young adults seek orthodontic treatment, often at the “Development of Intimacy” stage, there are two key questions, which are related but not the same: “Why are you seeking treatment, and why now as opposed to last year or next year?” and “What do you expect as a result of treatment?” The young adult’s goal usually is to improve the quality of life, including better success in developing intimacy. It is important to spend some time with the patient to be sure he or she understands that orthodontics at this stage of life has significant benefits, but it is not likely to solve problems related to difficulties in relationships with others.

Communication with Parents

The final stages in emotional development are “Guidance of the Next Generation”, in which the contrasts are Generativity vs Stagnation, and “Attainment of Integrity,” in which the contrasts are Integrity vs Despair.

Becoming a parent, and taking responsibility for guidance of the next generation, can be difficult for individuals with unresolved issues from the previous stages of emotional development.

Being a parent requires managing dental care along with other aspects of helping your child achieve maturity and independence. Almost all parents want the best for their children, but their approach toward achieving this varies greatly, based on their own emotional maturity, life experiences, and present circumstances. The result is that the parents’ attitudes can make successful treatment of their child very easy, very difficult, or anywhere in between.

This does not mean that a difficult parent is a bad person who is not trying to do the right thing for her (or his) children. All kinds of problems in the parent’s life can affect a child’s care (whether or not they have anything to do with the parent’s emotional maturity), and the dentist must keep in mind that the parent may be doing the best he or she can.

Communication with Parents (cont.)

The dentist who is to treat a child has no choice but to judge how well a parent is or isn’t maintaining the child’s oral health and arranging appropriate dental care. If you’re the dentist and recognize that a parent isn’t taking responsibility for problems with the child’s dental health or development of the dentition, it’s tempting to speculate about the parent’s motivation. Why is he or she that way? Can’t he or she see what this child needs?

Such speculation about the parent’s motives rarely is helpful. The dentist cannot create consistent, responsible behavior on the part of a parent. The dentist can, however, carefully think about what behaviors are needed from the parent, and then work to form a partnership with the parent so at least some of the necessary behaviors can be adopted to support the oral health of the child. The more the dentist can view the the relationship with a difficult parent as a problem to be solved, rather than as something that makes successful treatment of his or her child impossible, the more successful treatment will be.

The old adage, “Different strokes for different folks”, applies both to the appropriate management of children based on their developmental stage, and to the development of a relationship with parents that facilitates the child’s health care. Each parent is different, and each will have different specific barriers to supporting the oral health of the child. The dentist who can work productively with the parent to uncover the day-to-day barriers to good “oral health parenting” will ultimately find that a working relationship is possible, even with “difficult” parents.

Self-Test Referral

Understanding psychosocial development will help you communicate effectively with patients and parents of all ages. It might even help you understand yourself and your own relationships too.

Now that you have completed this module, be sure you have read pages 50-64 in the 5th edition of Contemporary Orthodontics​ (4th ed., pages 58-70) before you take the self-test in the following section. Then use the self-tests for all the modules in this course to prepare for the final examination.

Self-Test

Question 1

Which of the following is not a mechanism by which behavioral responses are learned?

1. parental instruction ✓
2. classical conditioning
3. operant conditioning
4. observational learning

Correct

That’s correct. The three distinct mechanisms by which behavioral responses are learned are classical conditioning, operant conditioning, and observational learning. Parental instruction could relate to any of these (though observation of what the parent does is more important than what he or she said), but it is not a distinct mechanism.

Incorrect

No, that’s incorrect. The three distinct mechanisms by which behavioral responses are learned are classical conditioning, operant conditioning, and observational learning. Parental instruction could relate to any of these (though observation of what the parent does is more important than what he or she said), but it is not a distinct mechanism.

Question 2

(A) Classical conditioning is particularly important in young children because (B) even young children can generalize from associations between different stimuli.

1. A true, B true, A and B related ✓
2. A true, B true, A and B not related
3. A true, B false
4. A false, B true
5. A and B false

Correct

That’s right. The generalization from associations between different stimuli that is the heart of classical conditioning develops before a child is able to manage more complex conditions that exist with operant conditioning and observational learning, so it’s particularly important in young children.

Incorrect

No, that’s wrong. The generalization from associations between different stimuli that is the heart of classical conditioning develops before a child is able to manage more complex conditions that exist with operant conditioning and observational learning, so it’s particularly important in young children.

Question 3

(A) The consequence following a given behavior can be a stimulus affecting future behavior because (B) pleasure and praise following a behavior increases the chance of that behavior appearing again.

1. A true, B true, A and B related
2. A true, B true, A and B not related ✓
3. A true, B false
4. A false, B true
5. A and B false

Correct

That’s right, both statements are true but they’re not directly related in a cause and effect sense. Whether the consequence of behavior is pleasant or unpleasant, the chance of that behavior appearing again is affected. Pleasure and praise increases it; displeasure or pain decreases it. This, of course, is the heart of operant conditioning.

Incorrect

No, that’s not the best answer. Both statements are true but they’re not directly related in a cause and effect sense. Whether the consequence of behavior is pleasant or unpleasant, the chance of that behavior appearing again is affected. Pleasure and praise increases it; displeasure or pain decreases it. This, of course, is the heart of operant conditioning.

Question 4

Which of the following consequences is most effective in producing appropriate behavior when a child is receiving dental treatment?

1. reward ✓
2. escape
3. time-out
4. punishment
5. they’re equally effective

Correct

That’s right. Providing a reward for desired behavior, whether the reward is a tangible gift or just verbal praise, is by far the most acceptable and effective of the operant conditioning mechanisms in the dental office.

Incorrect

No, that’s wrong. Providing a reward for desired behavior, whether the reward is a tangible gift or just verbal praise, is by far the most acceptable and effective of the operant conditioning mechanisms in the dental office.

Question 5

Which of the following consequences is least effective in decreasing the chance of inappropriate behavior when a child is receiving dental treatment?

1. reward
2. escape
3. time-out ✓
4. punishment
5. they’re equally effective

Correct

That’s right, omission of a reward (time-out) might work in some situations in the dental office, but in the setting of dental treatment it is the least effective of the operant conditioning methods. Reward and escape would reinforce the inappropriate behavior and would not be indicated. Punishment has to be used very carefully, but a mild form of punishment in the form of voice control would be more likely to succeed, and if it did, positive reinforcement of the correct behavior would be used immediately.

Incorrect

No, that’s wrong. Omission of a reward (time-out) might work in some situations in the dental office, but in this context it is the least effective of the operant conditioning methods. Reward and escape would reinforce the inappropriate behavior and would not be indicated. Punishment has to be used very carefully, but a mild form of punishment in the form of voice control would be more likely to succeed than omitting a reward, and if it did, positive reinforcement of the correct behavior would be used immediately.

Question 6

(A) A child who receives rewards for good behavior at the pediatrician’s office is likely to behave well initially at the dentist’s office because (B) given the similarity of the situation, he or she will anticipate a reward from the dentist as well.

1. A true, B true, A and B related ✓
2. A true, B true, A and B not related
3. A true, B false
4. A false, B true
5. A and B false

Correct

That’s correct, a child who is rewarded at the pediatrician’s office is likely to expect a reward from the dentist—and may eventually behave better for the pediatrician than the dentist if he or she doesn’t get it.

Incorrect

No, that’s wrong. A child who is rewarded at the pediatrician’s office is likely to expect a reward from the dentist—and may eventually behave better for the pediatrician than the dentist if he or she doesn’t get it.

Question 7

Which of the following affect the chance that a child who has acquired a behavior (by observing it) will actually display it?

1. behavior of a parent
2. behavior of an older sibling
3. behavior of the peer group
4. observed punishment for the behavior
5. observed reward for the behavior
6. 1, 4, and 5
7. 2, 3 and 4
8. 4 and 5
9. 1, 2 and 3
10. all of the above ✓

Correct

That’s right, all of these will affect the chance that a behavior acquired by observing it will actually be performed. Parents, older siblings and peers all have an influence as role models, and a child is much more likely to perform a behavior if he or she sees it being rewarded than if it is punished. The performance of the behavior is affected either way.

Incorrect

No, that’s wrong. All of these will affect the chance that a behavior acquired by observing it will actually be performed. Parents, older siblings and peers all have an influence as role models, and a child is much more likely to perform a behavior if he or she sees it being rewarded than if it is punished. The performance of the behavior is affected either way.

Question 8

Which of these stages of emotional development is expected at ages 3-6?

1. development of personal identity
2. development of autonomy
3. development of basic trust
4. development of initiative ✓

Correct

That’s right, the expected stage of emotional development at ages 3-6 is development of initiative. The child should have succeeded by then in establishing basic trust vs mistrust, and in developing autonomy vs shame and mistrust. Development of personal identity occurs during adolescence.

Incorrect

No, that’s incorrect. The expected stage of emotional development at ages 3-6 is development of initiative. The child should have succeeded by then in establishing basic trust vs mistrust, and in developing autonomy vs shame and mistrust. Development of personal identity occurs during adolescence.

Question 9

(A) An adolescent who is being pushed by his parents to have orthodontic treatment is likely to become a cooperative patient because (B) his parents are likely to offer rewards for good behavior.

1. A true, B true, A and B related
2. A true, B true, A and B not related
3. A true, B false
4. A false, B true ✓
5. A and B false

Correct

That’s right, the first statement is false although the second one frequently is true. An adolescent who is fighting for independence from his parents sometimes makes the orthodontic treatment a battlefield, and refuses to cooperate just to the parents. It’s important for the treatment to be his idea, or at least something he has agreed to. Otherwise orthodontics can be a bad experience for the patient, family and orthodontist.

Incorrect

No, that’s not the best answer. The first statement is false although the second one frequently is true. An adolescent who is fighting for independence from his parents sometimes makes the orthodontic treatment a battlefield, and refuses to cooperate just to be independent from the parents. It’s important for the treatment to be his idea, or at least something he has agreed to. Otherwise orthodontics can be a bad experience for the patient, family and orthodontist.

Question 10

Which of the following are characteristics that an adolescent who never resolved basic trust vs mistrust might display during dental or orthodontic treatment?

1. frightened
2. uncooperative
3. may require voice control for management
4. can become an acceptable patient after special effort
5. 1 and 2
6. 3 and 4
7. 1,2 and 3
8. 1,2 and 4 ✓
9. all the above

Correct

That’s correct. An adolescent like this is likely to be frightened and uncooperative, and can become an acceptable patient after special effort, but he is a poor candidate for any type of punishment in the dental office, even the mild form of voice control. Reassurance and careful management to build up trust are required.

Incorrect

That’s wrong. An adolescent like this is likely to be frightened and uncooperative, and can become an acceptable patient after special effort, but he is a poor candidate for any type of punishment in the dental office, even the mild form of voice control. Reassurance and careful management to build up trust are required.

Question 11

Which of the following are characteristics that a mother who never resolved intimacy vs isolation might display when her child needs dental treatment?

1. difficulty in following directions
2. missed appointments
3. self-centered, self-indulgent behavior
4. appearance of indifference to the child’s needs
5. 1 and 2
6. 3 and 4
7. 1, 2, and 3
8. 1, 2, and 4
9. all the above ✓

Correct

That’s right. A mother who never resolved the problems of intimacy vs isolation is likely to show all these characteristics when she deals with a dentist who is treating, or trying to treat, her child.

Incorrect

That’s wrong. A mother who never resolved the problems of intimacy vs isolation is likely to show all these characteristics when she deals with a dentist who is treating, or trying to treat, her child.

Question 12

(A) In the preoperational period of cognitive development, it appears that a child’s thought processes are like those of adults because (B) a child at this stage begins to use language in ways similar to adults.

1. A true, B true, A and B related ✓
2. A true, B true, A and B not related
3. A true, B false
4. A false, B true
5. A and B false

Correct

That’s right, both statements are true and they’re related. Children at this stage use language in a way similar to adults, and so may seem to be thinking like an adult, but their thought processes are distinctly different. Because they use words to symbolize the appearance of objects, they often do not recognize function or other characteristics, and thus may understand something quite different from a word than an adult would.

Incorrect

No, that’s wrong, both statements are true and they’re related. Children at this stage use language in a way similar to adults, and so may seem to be thinking like an adult, but their thought processes are distinctly different. Because they use words to symbolize the appearance of objects, they often do not recognize function or other characteristics, and thus may understand something quite different from a word than an adult would.

Question 13

Which of the following are characteristics of a child in the period of concrete operations?

1. improved ability to solve problems by reasoning
2. animism reduced but still present
3. ability to see another point of view still missing
4. development of ability to manage abstract concepts
5. 1 and 2 ✓
6. 3 and 4
7. 1, 2, and 3
8. 1, 2, and 4
9. all the above

Correct

That’s right, the first two statements are characteristics of the period of concrete operations, while the last two are not. At this time, a child can use a limited number of logical processes, especially when this involves objects that can be handled and manipulated, but still lacks the capacity to deal with abstract concepts. Animism is less important than in the previous stage but still is present, and the ability to see another point of view emerges.

Incorrect

No, that’s wrong. The first two statements are characteristics of the period of concrete operations, while the last two are not. At this time, a child can use a limited number of logical processes, especially when this involves objects that can be handled and manipulated, but still lacks the capacity to deal with abstract concepts. Animism is less important than in the previous stage but still is present, and the ability to see another point of view emerges.

Question 14

At what age does a child typically develop the thought processes that are characteristic of an adult?

1. 11 ✓
2. 12
3. 13
4. 14
5. 16

Correct

That’s right, adult thought processes appear at about 11 in most children, and at that point a child should be treated as an adult, not “talked down to”. This doesn’t mean, of course, that he or she will behave like an adult, just that learning now is done in the same fashion as adults.

Incorrect

No, that’s wrong. Adult thought processes appear at about 11 in most children, and at that point a child should be treated as an adult, not “talked down to”. This doesn’t mean, of course, that he or she will behave like an adult, just that learning now is done in the same fashion as adults.

Question 15

Which of the following are characteristic of an adolescent?

1. high susceptibility to peer role models
2. assumption that others will not notice what he or she is doing
3. feeling of uniqueness
4. lack of concern about risky behavior
5. 1 and 2
6. 3 and 4
7. 1, 2, and 3
8. 1, 3, and 4 ✓
9. all the above

Correct

That’s right, the first, third and last statements are correct but the second one is not. Adolescents have a high susceptibility to peer role models, in part because they assume that others are carefully noticing what they are doing. Their feeling of uniqueness (their personal fable) leads to a lack of concern about risky behavior.

Incorrect

No, that’s wrong. The first, third and last statements are correct but the second one is not. Adolescents have a high susceptibility to peer role models, in part because that they assume that others are carefully noticing what they are doing. Their feeling of uniqueness (their personal fable) leads to a lack of concern about risky behavior.