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“DIFFERENT FEATURES OF PREOPERATIONAL STAGE OF
CHILD COGNITION AND ITS APPLICATION IN BEHAVIOUR
MODIFICATION”
Submitted By
Dr. DHANYA K B
Dissertation Submitted to the
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA,
In partial fulfillment
Of the requirements for the degree of
MASTER OF DENTAL SURGERY
In
DEPARTMENT OF PEDODONTICS AND PREVENTIVE
DENTISTRY
Under the guidance of
Dr. SAVITHA N S, MDS
Senior Professor and Head
Department of Pedodontics and Preventive Dentistry
KVG DENTAL COLLEGE AND HOSPITAL,
SULLIA, DAKSHINA KANNADA
2015- 2018
v
ACKNOWLEDGEMENT
“Gurur brahma gurur vishnu guru devo mahesvarah
guru saksat parabrahma tasmai sree gurave namah”
Behind every achievement lies an unfathomable sea of gratitude to those who
made it true, without whom it would have never been in existence. To them I lay my
words of gratitude deep from my heart.
First and foremost, I bow to the Almighty, for giving me the strength and
capacity to complete this work. Thank you for all the blessings and everything you
gave me.
“A teacher is the one who can inspire hope, ignite imagination and instill love
of learning”. I am immensely pleased to place a record on my profound gratitude and
heartfelt thanks to my teacher and guide, Dr Savitha N S, Sr. Professor and Head,
Department of Pedodontics and Preventive dentistry, KVG Dental college and
Hospital Sullia, who has encouraged me all these three years, a true mentor who
motivated me always saying “If There Is a Will There Is a Way”. Her insight into the
field of learning, critical thinking, motivation and exemplary guidance throughout the
course of my dissertation is the prime reason for making it possible today. I deem it
my privilege to have my postgraduate course under her able guidance. I remain ever
grateful to you madam.
I am extremely grateful to Dr Moksha Nayak, MDS, K.V.G Dental College &
Hospital, for giving me an opportunity to conduct my study and letting me avail all
possible facilities form this esteemed institution.
I am privileged to convey my sincere gratitude to my respected teachers
Dr .Krishnamoorthy SH & Dr. Ambili Ayiliyath, Readers and Dr. Nisma Zahoor &
vi
Dr. Allwin Antony Thottathil Senior Lecturers Department of Pedodontics and
Preventive Dentistry, K.V.G Dental College & Hospital, Sullia for their valuable
support, apt guidance and constant encouragement throughout my academic tenure. I
express my heartfelt thanks for all the valuable suggestions, advices and support
given to me all these three years.
Friendship is the only pillar of life that you can lean on in both good times
and the bad. I am extremely indebted to my batch mates, Dr Jerry George and
Dr Musaffar. Their advices and opinion even on the smallest details has been of
great help and encouragement. From the core of my heart I thank my seniors
Dr Aiswarya, Dr Divyia, Dr Shashikala, Dr Sharath Chandra and Dr Somesh
kishor. Words are short to express my deep sense of gratitude to all of you. My
heartfelt thanks to my juniors
Dr Anjana, Dr Sruthy and Dr Vinodhini, and sub juniors Dr Vijay, Dr Philu
and Dr Neethu for their help and care during the course of my study. I owe my
gratitude to Dr, Jaseela, Dr.Vintu, Dr. Shruthi, and all my friends for their constant
support and encouragement.
I would like to express my gratitude to Dr. Rekha R, Statistician, KVG
Medical College and Hospital, Sullia for her helping hands in the completion of my
study and also for the painstaking analyses of the data and its tabulations.
My heartfelt thanks to the non- teaching staffs in the Department of
Pedodontics, for their help and cooperation during my post graduate course.
I express my earnest thanks to my father, Kamalakshan K B; mother,
Sarojini M, for all the pains that they have taken; without your support, inspiration
and drive, I might not be the person I am today. I also thank my in-laws, Vijayan V K
and Sathi K V for their constant support for understanding me and encouraging me. I
vii
have no words to acknowledge my husband, Jishin V K, for the sacrifice he made and
the dream he had to let go just to give me a shot at achieving mine. I also extend my
thanks to my brother n sisters, Deepthi K B, Jibin V K, Nimisha & Jasna and my
cutie pies Snigdha & Bhagat for their constant love and support.
This acknowledgment is incomplete without thanking my patients who played
the major role by giving consent to be the part of the study and making it possible.
Last but not the least I would like to thank all my friends, well-wishers and
names which I might have missed, who directly or indirectly contributed a lot to
accomplish my studies and this thesis.
Date: 27-11-2017
Place: Sullia
Dr. DHANYA K B
viii
LIST OF ABBREVIATIONS USED
(In alphabetical order)
AMR Behaviour of the child after the application of behaviour
management strategy
AVD Audiovisual distraction
BMP behaviour management problems
BMR Behaviour of the child before the start of the procedure
BT Beaker test
CFSS-DS Dental Subscale of the Children’s Fear Survey Schedule
CT Coin test
DV video- taped with a fixed digital video recorder
FIS Facial Image Scale
GA General Anesthesia
HOME Hand Over Mouth Exercise
HOME
Inventory
Home Observation for Measurement of the Environment
Scale
IQ Intelligence Quotient
MVARS Modified Venham’s clinical ratings of anxiety and
cooperative behaviour scale
N Negative
P Positive
PDT Policeman doll test
SDQ Strengths and Difficulties Questionnaire
TSD Tell Show Do
ix
VAS Visual analogue scale
VCARS Venham’s clinic anxiety rating scale
VCBRS Venham’s cooperative behaviour rating scale
VR Virtual reality
x
LIST OF TABLES
Sl. No. Tables Pages
1 Table 1: Showing frequency of distribution of total sample size
of 200 into 4 equally divided age based groups.
25
2 Table 2: Showing gender distribution out of 200 sample size,
47.5 % were females and 52.5 % were males.
26
3 Table 3: Showing manifestation of egocentrism feature based on
policeman doll test
27
4 Table 4: Showing manifestation of centration feature based on
classical beaker test
28
5 Table 5: Showing manifestation of centration feature based on
Coin test
29
6 Table 6: Showing distribution of cognitive features based on
number of children
31
7 Table 7: Showing distribution of cognitive features based on
percentage of children
31
8 Table 8: Showing behaviour rating of the child before the start of
the procedure
32
9 Table 9: Behaviour rating of the child after finishing the
procedure
33
10
Table 10: Showing behaviour of the child before and after
behaviour modification
34
xi
11 Table 11: Showing correlation of children’s behaviour before
and after the behaviour modification strategy
35
12 Table 12: Showing correlation of children with manifestations of
different cognitive features
36
xii
LIST OF FIGURES AND GRAPHS
Sl. No. Figures / Graphs Pages
1 Figure 1: Schematic Representation Of Policemann Doll Test 75
2 Figure 2: Model prepared - The Policemann Doll Test For
The Conduction of The Study
75
3 Figure 3: Child Performing Policaman Doll Test 76
4 Figure 4: Child Performing Policaman Doll Test 76
5 Figure 5: Schematic Representation Of Beaker Test 77
6 Figure 6: Child Performing Beaker Test 77
7 Figure 7 : Schematic Representation Of Coin Test 78
8 Figure 8 : Schematic Representation Of Coin Test 79
9 Figure 9: Behaviour Management Using Egocentrism Termed
As Amelioration.
80
10 Figure 10: Behaviour Management Using Centartion Termed As
Amelioration.
81
11 Graph 1: Showing gender distribution out of 200 sample
size.
26
12 Graph 2: Manifestation of egocentrism feature based on
policeman doll test
27
13 Graph 3: Manifestation of centration feature based on
classical beaker test
28
14 Graph 4: Manifestation of centration feature based on coin test
29
xiii
15 Graph 5: Showing manifestation of cognitive features in each
age group
30
16 Graph 6: Behaviour rating of the child before the start of the
procedure
33
17 Graph 7: Behaviour rating of the child after finishing the
procedure
34
18 Graph 8: Showing behaviour of the child before and after
behaviour modification
35
xv
STRUCTURED ABSTRACT WITH KEY WORDS
Title: Different Features of Preoperational Stage of Child Cognition and its
Application in Behaviour Modification
Background & Objectives: Child Psychology and cognition explains child’s growth
from birth to adolescence mapping children’s mental, cognitive, physiological,
intellectual developments. Piaget explains Preoperational stage exhibiting
egocentrism and centration. This study is first of its kind introducing pioneer and
novel behaviour management strategy “Amelioration” meaning an act of making
better.
Objective is to evaluate whether the psychological features explained by Piaget six
decades ago for child of preoperational stage are still valid in present generation of
children and then to apply these features for behavior modification as new behaviour
management strategy: Amelioration.
Methods: A cross-sectional study with 200 subjects divided into four groups on the
basis of age from 4-7. Manifestation of preoperational feature was assessed by 3
experiments: policeman doll test, coin test and beaker experiment. Depending on most
pronounced feature, behaviour management strategy based on the cognitive
development of the child was used for framing a better foundation and cooperation in
child. Frankl’s behaviour rating scale was used before and after application of
behaviour management strategy.
xvi
Results: 94% children showed egocentrism and centration at age four which reduced
eventually as child grew from age 4 to 7 and reduction of features as age increases,
was in-contrast to the finding of Piaget put forth 6 decades ago. Our study showed
that cognitive features mainly egocentrism and centration were still valid in present
generation children. Clinical application of these cognition based behaviour
management strategy gave better patient cooperation and study was statistically
significant at p<0.001.
Interpretation & Conclusion: Cognitive features egocentrism and centration were
still valid in children of present generation and cognitive feature based behaviour
modification techniques are the best method for eliciting cooperative response from
child and it can be considered as novel behaviour management strategy for better
patient cooperation.
Keywords: Cognition; Preoperational stage; Ego-centrism; Centration; Behavior
management.
1
TITLE OF DISSERTATION
Different Features of Preoperational Stage of Child Cognition and its
Application in Behaviour Modification.
INTRODUCTION
"Don't become a mere recorder of facts, but try to penetrate the mystery of
their origin." Ivan Pavlov (1849-1936)1,2
“Intelligence is the ability to adapt to the environment to mapping into
physical, cognitive, social, and emotional development.”3 The recognition and
understanding of these factors are important from the point of view of successful
clinical pediatric practice.
The cognitive revolution in the field of psychology took place around 60 years
back. It focused on the important role of mental process in how children process
through the phases of growth and development. The famous psychologist Jean Piaget
concluded that children are not just miniature adults and in each stage, they
demonstrate new intellectual abilities and increasingly complex understanding of the
world. Each child expresses themselves in various behavior patterns.4,5
To know them
as a special individual and treat them successfully becomes a challenge to the world
of pediatric dentistry. In the recent years, the mental activities of child are
unavoidably different and far away from those of children who belonged to the older
centuries.
These fast developing changes in the aspect of psychology and intelligence
points towards a better and suitable world of pediatric practice.6 Knowing the
psychology of child helps manage them through following the cognitive development
2
and clinically apply these features in behavior modification, by which treating a child
patient becomes a success when the child leaves the clinic with a smiling face.
Here comes the importance of knowing the cognitive development in the child
which can help modify the behavior of the child as well as the fear and anxiety of the
child which develops when the child enters the dental clinic. Perceiving the
psychological status of the child tells us the stage of child’s mental development and
their level of understanding the world.7 Thereby the importance of knowing their
cognitive development which can help the pediatric dentist treat the patient in a
special and better way in which the dentist can modify the strategy of behavior
modification by clinically implicating the psychological characteristics seen in that
particular age of the child. Hence, the purpose of this study is to know whether the
psychological features explained by Jean Piaget for the age group of 4 to 6 years,
mainly egocentrism and centration are still valid in the newer generation children and
to clinically apply these features in behavior modification to form a novel and pioneer
behavior management strategy named “Amelioration”, which can build a foundation
and thereby instills a positive attitude towards dentistry.
Hence aim of the study is to evaluate whether the psychological features
explained by Jean Piaget for the age group of 4 to 7 years, mainly egocentrism and
centration are still valid in the newer generation children and to clinically apply these
features in behavior modification in a clinical setup by forming a novel and pioneer
behaviour management strategy named “Amelioration”
3
OBJECTIVES
To assess if Jean Piaget’s most accepted cognitive theory which was given 60
years back, is still applicable in Indian population in the present generation of
4 to 7 years children.
To find which specific age group showed better manifestation of the feature
and find the relation of age and cognitive features than what Piaget had found
in range of 4 to 7 years.
To make use of these features as a novel behaviour modification technique in
Paediatric Dentistry.
4
REVIEW OF LITERATURE
a) Review related to Cognitive developments of children in 4-7year age group.
In the year 1976, Kenneth H Rubin conducted a study to assess the negative
relationship between the incidence of non-social speech and the frequency of peer
interaction in natural settings. A total of 34 children attending the preschool were
selected as sample. Two procedures were carried out. One was the communicative
egocentrism in which speech of child was tape recorded during two 20 minutes free-
play periods. At the end of the 20 minute observation period, verbal data was
transcribed from tape recording. Second procedure carried out was social interaction,
the measure used to determine the frequency of child‘s social interactions adapted
from behaviour survey instrument by Katz. The results indicated that children who
used less egocentric speech in naturalistic social situations were those who were most
likely to interact with other children and to be interacted with by other children in like
situations. The coefficients of egocentrism found in the present study mirror those
found in the original Piaget source.8
Giovanni Delitala in 1996 reviewed on incorporating Piaget‘s theories into
behavior management techniques for the child dental patient. It dealt with
Psychologist Jean Piaget‘s contributions to knowledge of cognitive development in
children, relating it to behavior management techniques. Piaget theorized that
children‘s knowledge about reality is realized by features such as constructivism,
egocentrism etc. And Giovanni Delitala explains that the practitioner should try to
stimulate these needs to develop a positive dental experience, should recognize the
child‘s need to gather knowledge, stimulate his/her curiosity, and help to develop
5
positive and correct awareness about the world of dentistry. The dentist should let the
child patient know what is going on and have an active part in treatment. Watching all
procedures with a hand mirror and perceiving that they are making decisions
concerning their own treatment are ways to achieve this.9
George Boeree in 1999 presented a review on cognitive development theory
of Jean Piaget which presented an elaborated description of theories and details
explained by Piaget. He said that even infants have certain skills in regard to objects
in their environment and they collect and extend their schema by assimilation,
accommodation and adaptation. As the child grows through years they go through
different psychological stages and main stage where children of preschoolers are
consisted is the preoperational stage. He gives a hint on the special characters or
features seen in children of that age which are use of symbols, creative play,
egocentrism, centration etc. by using which molding a child accordingly becomes
easier. He also explains the other stages as sensorimotor, formal operational and
concrete operational stage through which a child undergoes to reach into an adult.10
Susanne Anjos Andrade et al conducted a cross-sectional study in the year
2005 to assess the association between quality of stimulation in the family
environment and child‘s cognitive development considering the impact of mother‘s
schooling on the quality of stimulation.The sample of 350 children aged 17-42
months was carried out in Brazil in 1999. A socio- economic questionnaire was used,
along with the Home Observation for Measurement of the Environment Scale
(HOME Inventory), and the Bayley Scale for Infant Development. There was a
positive and statistically significant association between quality of stimulation in the
6
family environment and child‘s cognitive development. Part of the effect was
mediated by the mother‘s working circumstances and educational level and verified
that a better quality of stimulation is provided for those who come early in the birth
order in family, and live with only a few others under five years of age. The study
findings show the pertinence to cognitive development of interventions which
improve the quality of the environment and the child-caregiver relationship. 11
A study was done by Rakesh Mittal and Meenakshi Sharma in the year
2012 with the aim to investigate the various psychological effects on children due to
dental treatment. 180 school going children of between 6 and 12 years were included
and divided into two groups, group 1 with 6-9 year old children and group 2 with 9-12
year old children Included children had to undergo certain dental treatments seven
days prior to the investigation. Each child was asked a set of questions. After that
child was asked to draw or write related to his experience regarding dental treatment.
Result showed that a majority of children (92.22 %) had a positive perception
indicating that dental treatment did not always present a psychologically traumatic
experience. Younger children had more negative experience than the older children.12
A cross-sectional study was conducted by Sharath Asokan, Sharmila
Surendran, Sureetha Asokan, Shivakumar Nuvvula in 2014 to assess the
prevalence of Piaget‘s cognitive principles among children belonging to
preoperational stage. A study group of 200 children, aged 4-7 years are included. The
typical features of this stage, such as egocentrism, concept of cardinal numbers based
on centration, lack of conservation, and reversibility were assessed to check their
validity and prevalence among the children in this generation, using three tangible
7
experiments and two interview questions. A comparison of the prevalence of each
character was carried out among the children based on their age. All the three features
assessed were observed in most of the children between 4 and 7 years of age as
described by Piaget and most of his principles still appear valid today.13
B) Review related to different behaviour management techniques:
A study was done by Barbara G Melamed, Donald Weinstein, Roland
Hawes, and Marjorie Katin Borland in 1975 with the aim to determine with coping
mechanisms if watching a videotape of a peer undergoing dental treatment
successfully would reduce anxiety- related, disruptive behavior in a group of child
dental patients. Fourteen children were selected as experimental group and fourteen as
controls. Control group was given drawing task and experimental group with film
modelling. and children‘s cooperation was assessed using fear survey schedule.
Result showed no significant group differences for the first two sessions. However,
those children who viewed the videotaped model at session 3 were able to maintain a
low level of disruptive behavior despite the increased demands and actual pain
involved in the treatment session. They concluded saying that in a practical sense the
showing of a film can be incorporated easily in the private dental office or clinics
where low staff-patient ratios make behavioral preparation of patients inefficient.14
Lawrence J. Siegel and Lizette Peterson in 1980 did a study to investigated
the effects of sensory information and coping skills on the responses of preschool-
aged children to their initial dental treatment visit. The subjects were 42 children of
42 to 71 months attending a day- care preschool program for low-income families.
Two independent observers rated the child's behavior during the dental session, using
8
the Behavior Profile Rating Scale, which assesses the frequency of the child's anxiety-
related behaviors that interfere with dental treatments. Self-reported anxiety was
measured using the Venham Picture Test before and after each dental session. In the
coping skills condition, the children were taught general body relaxation, deep and
regular breathing, and the pairing of relaxing cue words calm and nice. These results
indicated that children who received either sensory information about the dental
experience or a coping skills treatment package displayed fewer disruptive responses,
were rated as less anxious and distressed and more cooperative.15
Keith D Allen et al in 1990 conducted a study in which they performed a
survey to provide an assessment of the types of management needs and management
techniques currently used by pediatric dentists. Three hundred members of the
Academy with Diplomate status were selected randomly and sent surveys concerning
their exposure to new developments in behavior management and their current use of
both traditional and newer behavior management techniques. Traditional management
practices considered included sedation, restraint, hand-over-mouth, verbal reprimand,
tell-show-do, non-contingent prizes, parents in operatory, and stopping treatment.
Newer, nontraditional management practices included relaxation, contingent rewards,
distraction, and filmed and live modeling. The procedures are ranked according to the
reported frequency of usage in managing all types of children during restorative
dental treatment. Tell-show-do and the delivery of a prize (independent of the child‘s
behavior), are the management strategies reported used by most dentists, followed by
verbal reprimand and sedation. Less than 5%(8) of the respondents have used
contingent distraction or filmed modeling. They concluded saying Pediatric dentists
reported the need for improved and expanded behavioral management technology.16
9
Grewal N in 2003 conducted a study with the purpose to identify behaviour
management techniques commonly utilized by pediatric dentists in Punjab and assess
the change in their utilization pattern in the past five years. In addition, the study
identified changes in parental attitude towards behaviour management techniques.
These techniques include, Tell Show Do (TSD), Hand Over Mouth Exercise
(HOME), Physical restraints, conscious sedation and General Anesthesia (GA). A
total number of 54 pediatric dentists participated in this study by filling up
information on a questionnaire. Results showed that when assessing the type of
behaviour management techniques used by them, 93% of the respondents followed
normal conversation, whereas 70% responded that they used Tell Show Do technique
and they concluded that there has been an increase in the use of behaviour
modification techniques while treating child patients in the clinic as compared to
previous years.17
Bin Xia, Chun-Li Wang & Li-Hong Ge in 2011 conducted a study with the
aim to determine the prevalence of children‘s dental behaviour management problems
(BMP) in clinic, investigated the influence of non-dental and dental background
variables on BMP, and analyzed the predictive power of these variables. study
included 209 children (91 female, 118 male) aged 2–8 years. Guardian was made to
answer a standardized questionnaire with questions covering the child‘s personality
factors, previous dental and medical treatment experience, etc. The behavior
techniques included communication, positive reinforcement, tell-show-do, and
medical immobilization with a papoose board. Each child‘s dental treatment was
video- taped with a fixed digital video (DV) recorder focused on the child and dentist.
The entire DV record of each treatment was observe scored. Venham‘s clinic anxiety
10
rating scale (VCARS) and cooperative behaviour rating scale (VCBRS) were used for
assessment of child‘s behavior. Result showed more children with acceptable dental
behaviour. They concluded saying they found the presence of toothache to be a risk
factor for negative dental behaviour.18
Donna Koller, and Ran D. Goldman conducted a study in 2012 with the
purpose to provide a critical assessment of the evidence-based literature that can
inform clinical practice and future research. Distraction is a commonly used
nonpharmacological pain management technique used by both health care
professionals and parents to attenuate procedural pain and distress. Distraction
operates on the assumption that by shifting a child's focus to something engaging and
attractive, his or her capacity to attend to painful stimuli is hindered, thereby reducing
pain, distress, and anxiety. In pediatrics, distraction is often defined as a strategy—
whether cognitive or behavioral— that draws a child's attention away from noxious
pain stimuli and it is a cognitive coping strategy that passively redirects the subject's
attention or actively involves the subject with a task. Because of the number of
techniques cited in the literature, evidence is examined and organized under main
categories of active and passive forms of distraction. Active forms of distraction
include interactive toys or electronic games, virtual reality (VR), controlled breathing,
and guided imagery/relaxation. In the case of active distraction, participants are
typically coached by an adult to engage in the activity. Passive forms of distraction
predominantly consist of listening to a story or music, viewing television, or watching
movies. 19
11
A study was done by Paryab M, Arab Z, 2014 in India with the aim to
evaluate the effect of Filmed modeling in comparison with commonly used Tell-
Show-Do technique (TSD) on the anxious and cooperative behavior of 4-6 years old
children during dental practice. 46 children aged 4-6 years were enrolled in this study
and randomly allocated into two groups. Group I: At the first visit, the procedure of
Tell-Show-Do was done, Group II: At the first visit, children watched a film
consisting of the procedure of Tell-Show-Do performed on a child model. And at the
second visit, treatment procedures were performed in both the groups. During the
treatment procedure, index of heart rate was measured and behaviors of children were
recorded. The result obtained showed that there were no statistically significant
differences in heart rate measures, clinical anxiety and cooperative behavior scores of
children between the two groups (P = 0.6). And the study concluded that Filmed
modeling can be an efficient alternative method to Tell-Show-Do technique in pre-
appointment preparation of the 4-6 years old children during dental treatment.20
A study was done by Divya Singh, Firoza Samadi, J N Jaiswal, Abhay
Mani Tripathi, 2014, with the aim to evaluate the efficacy of ‗audio distraction‘ in
anxious pediatric dental patients. 60 children were randomly selected and equally
divided into two groups of 30 each. The first group was control group (group A) and
the second group was music group (group B). The dental procedure employed was
extraction for both the groups. The children included in music group were allowed to
hear audio presentation throughout the treatment procedure. Anxiety was measured by
using Venham‘s picture test, pulse rate, blood pressure and oxygen saturation. ‗Audio
distraction‘ was found efficacious in alleviating anxiety of pediatric dental patients.
12
And the study concluded with proving that ‗audio distraction‘ did decrease the
anxiety in pediatric patients to a significant extent.21
Ritika Sharma, Nanika Mahajan, Shefali Thakur, Bhanu Kotwal, 2014
reviewed on Behavior Management Strategies while treating children with dental fear.
It described the various behavior management techniques like the tell- show-do,
reinforcements, voice control, and hand over mouth exercises that offer promise for
dentists managing disruptive children from a behavioral science perspective. Basic
Behavior Guidance Techniques like Creating a positive first impression which
describes on tell show do (TSD), Modelling, Distraction, Voice Control, Contingent
Escape etc and they drew an approach for managing child in a schematic approach.
They concluded suggesting that in dealing with a child with dental anxiety, it is
extremely important to complete the treatment. Successful treatment completion not
only has implications for dental health, but also allows the child to realize that the
procedure was not nearly as aversive as they had been expected. This confidence will
likely enable the child to confront future dental appointments with less anxiety.22
C) Review based on clinical management strategies
Jennifer Creem Aitken, Stephen Wilson, Daniel Coury, Amr M. Moursi
conducted a study in 2001 with the purpose to determine if audio distraction could
decrease patient anxiety, pain and disruptive behavior during pediatric dental
procedures. The sample consisted of 45 children 4- to 6-year olds who required
restorative dental treatment with local anesthesia on both mandibular quadrants and
had demonstrated ―positive‖ to ―negative‖ behavior (Frankl 3 or 2). Behavior
management techniques of tell-show-do and voice control were used. The parent was
13
asked to complete a Modified Corah Anxiety Scale Questionnaire while the child was
in the dental operatory. Heart rate was recorded at intervals. A post-operative Venham
picture test and a visual analogue scale, to measure patient-perceived pain, were
administered. Result demonstrated that there was no significant difference in age
among the three groups and study concluded saying despite a lack of an effect on pain
and anxiety levels, patients had an overwhelmingly positive response to the music and
would choose to listen to it at subsequent visits.23
A study was conducted by Diana Ram et al in the year 2010 with the aim to
investigate the effect of audiovisual distraction (AVD) with video eyeglasses on the
behavior of children undergoing dental restorative treatment and the satisfaction with
this treatment as reported by children, parents, dental students, and experienced
pediatric dentists. The study was conducted with treatment under wireless audiovisual
eyeglasses with earphones and under nitrous oxide sedation. A Frankl behavior rating
score was assigned to each child. After each treatment, a Houpt behavior rating score
was recorded by an independent observer. A visual analogue scale (VAS) score was
obtained from children who wore AVD eyeglasses, their parents, and the clinician.
Results of the study showed General behavior during the AVD sessions, as rated by
the Houpt scales, was excellent for 70% of the children including those with poor
Frankl ratings, to be satisfied with the AVD eyeglasses. Satisfaction of parents and
clinicians were also high. Concluded suggesting Audiovisual eyeglasses offer an
effective distraction tool for the alleviation of the unpleasantness and distress that
arises during dental restorative procedures.24
14
A non-randomised crossover trial was conducted by F. Guinot Jimenoet al
in 2014 with the aim to evaluate whether the parental perception of the patient‘s
anxiety, children‘s anxiety, pain, behaviour and heart rate of pediatric patients
improves when an audiovisual technique is used as a distraction method during dental
treatment. Study consisted 34 patients aged 6–8 years, who required a minimum of
two treatment visits for restorative therapy. During the last visit, the patient was
shown a cartoon film. The result demonstrated that There was a significant
improvement in the global behaviour when children were shown a cartoon film (P <
0.001). A significant increase in heart rate was recorded in both visits when the
anesthetic was injected. The study concluded with suggesting that the use of the
audiovisual material used as a method of distraction produces a global improvement
in patient behaviour, but not in parental perception of the patient‘s anxiety, self-
reported anxiety, pain or heart rate according to the measurement scales used.25
Amal Al-Khotani, Lanre A’aziz Bello and Nikolaos Christidis in 2016
conducted a study with aim to evaluate the effectiveness of viewing videotaped
cartoons using an eyeglass system (i-theatreTM) as an audiovisual distraction
technique on behaviour and anxiety in children receiving dental restorative treatment.
Methods included Fifty-six consecutive children patients who presented for treatment
and met inclusion criteria were included and randomly divided into two groups; a
control group without distraction (CTR-group) and a distraction-group (AV-group).
Three dental treatment visits were provided for each patient. Anxiety and cooperative
behaviour were assessed with the Facial Image Scale (FIS) and the Modified
Venham‘s clinical ratings of anxiety and cooperative behaviour scale (MVARS). The
vital signs, blood pressure and pulse were also taken. Results showed that AV-group
15
showed significantly lower MVARS scores than the CTR-group, and the scores
decreased significantly during treatment in the AV-group. Further, the pulse rate was
significantly increased in the CTR-group during injection with local anesthesia, but
not in the AV-group and the study concluded with AV-distraction seems to be a
useful tool to decrease the distress and dental anxiety during dental treatment.26
Sindura Allani & Jyothsna V Setty in 2016 conducted a study with the aims
and objectives to investigate the effect of distraction with a mobile phone video game
in comparison with video viewing on the behavior of children undergoing local
anesthesia injection. Methods included 30 children in the age group of 4-8 years with
Frankel‘s behavior rating score of 2 who required local anesthesia for dental
extraction were selected with group 1 playing video game on the mobile phone and
group 2 viewing videos of patient‘s favorite cartoon character on mobile phone as
means of distraction during the preoperative period and during the course of the
dental procedure. Results showed that Mobile phone video games were found to be
more effective for distracting kids in the dental operatory than viewing videos.
Preoperative anxiety was found to be highly reduced with this method of distraction.
The study concluded suggesting that a cartoon video or video game on a mobile
phone can be offered to most children as they are easy to implement, portable, and
effective method to reduce anxiety in the preoperative area and during injection of
local anesthesia for dental extraction.27
D) Review related to application of cognitive developments:
Lawrence J. Siegel and Lizette Peterson conducted a study in 1980 which
investigated the effects of sensory information and coping skills on the responses of
16
preschool-aged children to their initial dental treatment visit. The subjects were 42
children attending a day- care preschool program for low-income families. The
children were closely matched for age, sex, and race and were then randomly assigned
to one of three treatment conditions. Two independent observers rated the child's
behavior during the dental session, using the Behavior Profile Rating Scale, which
assesses the frequency of the child's anxiety-related behaviors that interfere with
dental treatments. Following each dental session, the dentist and observer
independently rated the child's level of cooperation and anxiety on a 7-point scale
where they could draw the conclusion that child could be molded to cooperative if we
consider coping as behaviour management strategy.28
A study was conducted by S Michie, M Johnston, C Abraham, R Lawton,
D Parker, A Walker in the year 2004 with aim on the development of a consensus
on a theoretical framework that could be used in implementation research. The
objectives were to identify an agreed set of key theoretical constructs for use in
studying the implementation of evidence based practice and developing strategies for
effective implementation, and to communicate these constructs to an interdisciplinary
audience. The contributors were a ‗‗psychological theory‘‘ group (n = 18), a ‗‗health
services research‘‘ group (n = 13), and a ‗‗health psychology‘‘ group (n = 30).
Twelve domains were identified to explain behaviour change such as knowledge,
skills, social/ professional role and identity, beliefs about capabilities, beliefs about
consequences etc. They concluded suggesting a set of behaviour change domains
agreed by a consensus of experts which was available for use in implementation
research. Applications of this domain list was enhancing the understanding of the
17
behaviour change processes inherent in implementation of evidence-based practice
and was also tested the validity of these proposed domains.29
Debbie Bonetti et al in the year 2006 conducted a cross- sectional study
which applied psychological theory to the implementation of evidence-based clinical
practice. Objectives were to see if variables from psychological frameworks
(developed to understand, predict and influence behaviour) could predict an evidence-
based clinical behavior and to develop a scientific rationale to design or choose an
implementation intervention. The behavior was determined by the number of intra-
oral radiographs taken per course of treatment. Semi- structured interviews took place
in the practices of sixteen dentists, randomly identified. Responses were coded into
belief domains which were then used, in conjunction with the literature, to create the
items measuring variables from the psychological theories. The results suggested an
intervention targeting predictive psychological variables could increase the
implementation of this evidence-based practice and they concluded saying since
psychological frameworks incorporate methodologies to measure and change
component variables, and can identify factors predictive of clinical behaviour and for
the design and choice of interventions to modify practice as new evidence emerges.30
Martin P Eccles et al in 2007 conducted a study with the aim to explore the
usefulness of a range of psychological theories to predict health professional
behaviour relating to management of upper respiratory tract infections without
antibiotics. Theory-based cognitions were collected by postal questionnaire survey of
sample size of 200. Behavioral data was collected from routinely available
prescribing data, and planned analyses explored the predictive value of theory- based
18
cognitions in explaining variance in the behavioral data. Result suggested evidence
that the psychological models can be useful in understanding and predicting clinical
behaviour. And they concluded saying that the study provided evidence that
psychological models can be useful in understanding and predicting clinical
behaviour and taking a theory-based approach enables the creation of a replicable
methodology for identifying factors that predict clinical behaviour.31
Bobby Ojose conducted a study in 2008 with the aim of application of
Piaget‘s theory of cognitive development to mathematical instruction. As children
develop, they progress through stages characterized by unique ways of understanding
the world. During the sensorimotor stage, young children develop eye-hand
coordination schemes and object permanence. The preoperational stage includes
growth of symbolic thought, as evidenced by the increased use of language. During
the concrete operational stage, children can perform basic operations such as
classification and serial ordering of concrete objects. In the final stage, formal
operations, students develop the ability to think abstractly and metacognitively, as
well as reason hypothetically. This article articulated these stages in light of
mathematics instruction. In general, the knowledge of Piaget‘s stages helps the
teacher understand the cognitive development of the child as the teacher plans stage-
appropriate activities to keep the students active.32
J. Versloot, J.S.J. Veerkamp, J. Hoogstratenconducted a study in the year
2008 with the aim to examine the relationship between the levels of dental anxiety,
psychological functioning and earlier experience with dental injections and to study
the possible influence of these factors on children‘s behaviour before and during a
19
local analgesia injection. Study was conducted among 128 children aged 4-11 years.
The data was collected using Strengths and Difficulties Questionnaire (SDQ), to
assess behavioral problems and psychological functioning. Dental Subscale of the
Children‘s Fear Survey Schedule (CFSS-DS) was used to measure the level of dental
anxiety. The distress behaviour of the children was assessed using Venham‘s
(modified) clinical rating of anxiety and cooperative behaviour. The children were
videotaped from the moment they entered the treatment room until the end of the
local analgesia injection. The result found was, 65% had previous experience with a
dental injection. The mean score on the SDQ was 8.5 (SD±5.1) and 84% of the
children were considered to have a good level of psychological functioning. They
concluded suggesting children with high levels of dental anxiety, lower psychological
functioning and young children with recent dental experience showed more anxiety
and uncooperative behaviour before and during a dental injection. Therefore, it could
be helpful for a dentist to be aware of these factors and this should be taken into
account when planning dental treatment.33
Christine T. Chambers, Anna Taddio, Lindsay S. Uman and C. Meghan
Mc Murtry in 2009 conducted a systematic review to determine the efficacy of
various psychological strategies for reducing pain and distress in children during
routine immunizations in children between 2 and 18 years of age. A growing body of
literature on non- pharmacologic management of pediatric procedural pain, including
physical, operator-dependent, and psychological interventions has not been studied
much. Psychological interventions are recommended for use in managing children's
procedural pain, and these interventions are typically cognitive-behavioral in
orientation and highlighted the importance and value of psychological interventions
20
for reducing pediatric procedural pain and distress. The review investigated a broad
range of psychological interventions and found the most support for distraction,
hypnosis, and combined cognitive-behavioral interventions. They concluded
suggesting to examine which psychological interventions work best for children of
different ages and whether certain child characteristics (eg, temperament, anxiety
level, cognitive ability) warrant different types of psychological interventions.34
A study was conducted by in Enose M W Simatwa 2010 with the aim of
implication of Piaget‘s theory of intellectual development into instructional
management at pre-secondary school level. Piaget has postulated that children
progress through a series of four stages beginning with rudimentary reflex responses
and achieving full maturity with the attainment of formal deductive reasoning.
Piaget‘s theory also postulates that a child is an active investigator who acts upon his
environment with reflex responses during infancy and then with more complex
responses that emerge from early interactions. Piaget views interaction as a two-way
process, one of which is accommodation and the other is assimilation.
Accommodation and assimilation are reciprocal and their interaction generates
cognitive growth. Understanding and application of Piaget‘s Theory is important in
the effective enhancement of teaching and learning process at pre-secondary school
level. Consequently, teacher trainers, trainee teachers and practicing teachers need to
keep abreast of Piaget‘s theory of intellectual development. He explains that children
at various stages develops different levels of cognitive capability and knowing this
capacity and limitations of their brain and mental developments can modify strategy
for the child management in school level where they perform and understand the
classes in a different and cognition based manner and learning process should be
child-centered.35
21
METHODOLOGY
Source of Data
This clinical study was conducted among 200 children, aged 4-7 years,
reported to the Department of Paedodontics and Preventive Dentistry, KVG Dental
College and Hospital, Sullia.
Necessary permission was taken from parents of children before conducting
the study. Consents of subjects willing to participate in the study was obtained
(attached document).
The study was initiated subsequent to approval of K.V.G. Dental College
Ethical Committee. Subjects were selected based on the inclusion criteria and
consent of subjects willing to participate in the study was obtained in a given
format (attached document).
After getting informed consent, children were divided 50 in each group into 4
groups. All children were made to undergo the three experiments to find the
most prevalent feature, and based on this feature the behavior modification
was done for the child patient and behavior was recorded using Frankl
behavioral rating scale. Treatment procedure was done under well illuminated
light. All the procedures were done by a single examiner.
Method of Collection of Data:
200 subjects selected in the study was divided into four groups, (50 children in
each group) based on their age:
Group I : 4-years old
Group II : 5-years old
22
Group III : 6 years old
Group IV: 7 years old
Prevalence of cognitive principles in that age group was assessed by three
experiments such as policeman doll test, coin test and classical beaker experiment.
Depending on the group with more prevalent features was then again divided
and used in behaviour modification (using ego centrism and centration) of the child in
clinical setup.
Selection Criteria for Study Group
Inclusion Criteria:
1. Healthy children within the age group of 4-7 years.
2. Normal children without any serious debilitating disease.
3. Children with normal IQ level
4. Children with no co-ordination, conversation problem.
5. Children of Asian Indian origin.
Exclusion Criteria:
1. Patients with mental retardation, serious medical problems and other
congenital malformations.
2. Syndromic children.
3. Patients with no consent.
4. Children below 4 years and above 8 years.
5. Children of low IQ level
23
Armamentarium
Gloves
Mouth mask
Kidney tray
Mouth mirror
Probe
Explorer
Specifications on the dental chair like: three way syringe, illuminating light,
chair positioning buttons, water filling system etc.
Ultrasonic scalers
FRANKL’S BEHAVIOUR RATINGSCALE
Rating Behaviour Rating for child
patient under
treatment
1.Definitely negative Refusal of treatment, crying forcefully,
fearful, or any other overt evidence of
extreme negativism
2.Negative Reluctant to accept treatment,
uncooperative, some evidence of negative
attitude but not pronounced, sullen,
withdrawn
3.Positive Acceptance of treatment, at times
cautious, willingness to comply with the
dentist, at times with reservation but
patient follows thedentist's directions
cooperatively.
4.Definitely positive Good rapport with the dentist, interested in
the dental procedures, laughing and
enjoying the situation
(Figure 1 to 10)
24
SAMPLE SIZE OF ESTIMATION
p= 58%
q=(100-p) = 100-58 = 42
n = Z pq
l2
at confidence interval (C I) =99% Z=2.58
Error at 10%
Hence,
n= (2.58 * 2.58 * 58 * 42) (10 * 10)
= 165.
It is divided into 4 groups, hence, 165/4 = 41.2 41 (in each group)
Rounding off to 50 in each group.
So, the total sample size, n = 50 * 4= 200.
25
RESULTS
The data collected was entered into Microsoft excel spreadsheet and analyzed
using Statistical Package for Social Sciences (SPSS) version 20 (SPSS Inc. California,
USA). Descriptive data were presented in the form of frequencies, percentages, mean
and standard deviation.
Present study showed that there was an equal distribution of children into four
groups based on their age. When the gender distribution among the sample size was
evaluated, it was shown to be as 95 females and 105 male children giving a male
predominance in the sample. This is explained in the table 1 and 2 and graph 1.
Table 1: Showing frequency of distribution of total sample size of 200 into 4
equally divided age based groups.
Age group Frequency Percent
4 50 25.0
5 50 25.0
6 50 25.0
7 50 25.0
Total 200 100.0
26
Table 2: Showing gender distribution out of 200 sample size, 47.5 % were
females and 52.5 % were males.
Frequency Percent
F 95 47.5
M 105 52.5
Total
200
100.0
Graph 1: Showing gender distribution out of 200 sample size, 47.5 % were
females and 52.5 % were males.
Table 3 and graph 2 depicts the expression of egocentrism in children of
various age groups with the help of Policeman doll test in which age four group
consisted of the maximum percentage of children with egocentrism (94%). A
sequential decrease in egocentrism was noted with increase in age from 4 to 7 years
(34%).
Series1, F, 95, 47% Series1, M, 105,
53% F
M
27
Table 3: Showing manifestation of egocentrism feature based on policeman doll
test
Test 1: POLICEMAN DOLL TEST
Group N(egocentric) P(non-egocentric)
Group 4 47(94%) 3 (6%)
Group 5 21(42%) 29 (58%)
Group 6 24(48%) 26(52%)
Group 7 17(34%) 33(66%)
Total 109(54.5) 91(45.5)
Graph 2: Manifestation of egocentrism feature based on policeman doll test
The next test was to demonstrate the centration feature among 4 to 7 year
children which was done with the help of classical beaker test and coin test. Similar to
egocentrism feature, centration feature was most predominant in age four children
(68% & 70%) which sequentially decreased as the age increased from 4 to 7(36%
&42%) which was depicted in table 4 & 5 and graph 3 &4.
0
10
20
30
40
50
GROUP 4 GROUP 5 GROUP 6 GROUP 7
28
Table 4: Showing manifestation of centration feature based on classical beaker
test
Test 2: BEAKER TEST
Group N (centrated) P (non-centrated)
Group 4 34(68%) 16
Group 5 23(46%) 27
Group 6 24(48%) 26
Group 7 18(36%) 32
Total 99(49.5) 101(50.5)
Graph 3: Manifestation of centration feature based on classical beaker test
test 2: beaker test
test 2: beaker test
0
5
10
15
20
25
30
35
group4 group5 group 6 hroup 7
test 2: beaker test test 2: beaker test
29
Table 5: Showing manifestation of centration feature based on Coin test
Test 3; COIN TEST
Group N (centrated) P (non-centrated)
Group 4 35(70%) 15
Group 5 22(44%) 28
Group 6 21(42%) 29
Group 7 21(42%) 29
Total 99(49.5) 101(50.5)
Graph 4: Manifestation of centration feature based on coin test
0
5
10
15
20
25
30
35
group4 group5 group 6 hroup 7
30
Graph 5: Showing manifestation of cognitive features in each age group
Graph 5 demonstrated the presence of cognitive features in each age group in
4 different categories such as presence of only egocentrism, presence of only
centration, presence of both egocentrism and centration and absence of egocentrism
and centration. Both features were present the most with age four children (68%)
whereas the age seven children manifested with least number of children with
cognitive features. At seven years of age, around 42% of children demonstrated
absence of both the cognitive features which can be explained related to their
cognitive development or the environmental influence which helps in their cognition.
Table 6 explains the manifestation of cognitive features divided in four
different categories, such as presence of both centration and egocentrism in each age
groups, presence of only centration in each age groups, presence of egocentrism only
in each age groups, and absence of manifestation of both features in each age groups.
Here we can see that every age group children presented with cognitive features but
the number varied. Both features were seen highest in age four children whereas it
47
3
34
16
35
15 21
29 23
27 22
28 24 26 24 26
21
29
17
33
18
32
21
29
Total, Test 1 N, 109
Total, Test 1 P, 91
Total, Test 2 N, 99 Total, Test 2 P, 101 Total, Test 3 N, 99 Total, Test 3 P, 101
0
20
40
60
80
100
120
NTest 1
P NTest 2
P NTest 3
P
4 years 5 years 6 years 7 years Total
31
decreased to 9 when it reached at age 7 and similarly absence of both features were
seen the least in age four children which increased up to 21 at age seven, which states
that as the age increases there was a sequential reduction in the manifestation of f
cognitive features.
Table 7 explains the same, but in percentage values and the conclusions drawn
are also same.
Table 6: Showing distribution of cognitive features based on number of children
Group Presence of Both
Centration and
Egocentrism
Centration
only
Egocentrism
only
Absence of
both features
Group 4 34 1 13 2
Group 5 16 11 7 16
Group 6 16 9 9 16
Group 7 9 12 8 21
Total 75(37.5) 33(16.5) 37(18.5) 55(27.5)
Table 7: Showing distribution of cognitive features based on percentage of
children
Group Presence of Both
Centration and
Egocentrism
Centration
only
Egocentrism
only
Absence of
both features
Group 4 68% 2% 26% 4%
Group 5 32% 22% 14% 32%
Group 6 32% 18% 18% 32%
Group 7 18% 24% 16% 42%
32
The next table pinpoints towards the second section of the study where the
clinical application of the cognitive features in each group based on the most
prevalent manifestation of the feature were carried out. The data on the behaviour of
the child before the start of the procedure is shown in Table 8 and Graph 6 where the
children in the study were mostly definitely negative or negative. This children
belongs to the category where they need special understanding of their cognitive
development and care during the clinical procedure which can help build a firm
foundation for the future of the child.
Table 8: Showing behaviour rating of the child before the start of the procedure
AGE GROUP DEFINITELY
NEGATIVE
NEGATIVE TOTAL
4 32 18 50
4 (percentage) 29.9% 19.4% 25.0%
5 29 21 50
5(percentage) 27.1% 22.6% 25.0%
6 23 27 50
6(percentage) 21.5% 29.0% 25.0%
7 23 27 50
7(percentage) 21.5% 29.0% 25.0%
TOTAL 107 93 200
TOTAL 100.0% 100.0% 100.0%
33
Graph 6: Behaviour rating of the child before the start of the procedure
Table 9 and Graph 7 explains the change in behaviour of the child after the use
of specific and particular cognition based behaviour management strategy for each
child which showed promising results when the definitely negative and negative
children turned into positive and definitely positive children after the behaviour
management technique used which was named as “Amelioration”.
Table 9: Behaviour rating of the child after finishing the procedure
AGE GROUP POSITIVE DEFINITELY POSITIVE TOTAL
4 33 17 50
4 (percentage) 24.4% 26.2% 25.0%
5 37 13 50
5(percentage) 27.4% 20% 25.0%
6 30 20 50
6(percentage) 22.2% 30.8% 25.0%
7 35 15 50
7(percentage) 25.9% 23.1% 25.0%
TOTAL 135 65 200
BMR0
5
10
15
20
25
30
35
Group 4 Group 5 Group 6 Group 7
1
32 29
23 23
0
2
18 21
27 27
0
BMR
34
Graph 7: Behaviour rating of the child after finishing the procedure
Table 10 and Graph 8 shows the complete evaluation of the child’s behaviour
before and after the behaviour modification and the positive effect of behaviour
management strategy applied which helped the children to become very comfortable
and phobia free. It was seemed to be a successful strategy which developed better
patient cooperation and better acceptance of the clinical procedures.
Table 10: Showing behaviour of the child before and after behaviour
modification
BMR AMR
1 2 3 4 1 2 3 4
Group 4 32 18 - - - - 33 17
Group 5 29 21 - - - - 37 13
Group 6 23 27 - - - - 30 20
Group 7 23 27 - - - - 35 15
107(53.5) 93(46.5) - - - - 135(67.5) 65(32.5)
BMR0
5
10
15
20
25
30
35
Group 4 Group 5 Group 6 Group 7
1
32 29
23 23
0
2
18 21
27 27
0
BMR
35
Graph 8: Showing behaviour of the child before and after behaviour
modification
Table 11 shows the mean score of behaviour of children which was 1.36
before which came to 3.34 in age four children, 1.42 to 3.26 in age five, 1.54 to 3.40
in age six year old children accordingly and based on Wilcoxon signed ranks test it
was highly statistically significant for each age groups specifically.
Table 11: Correlation of children’s behaviour before and after the behaviour
modification strategy
MEDIAN MEAN Wilcoxon Signed Ranks
Test AMR - BMR
Group 1 BMR AMR BMR AMR
4 1.00 3.00 1.36 3.34 -6.389 .000
5 1.00 3.00 1.42 3.26 -6.341 .000
6 2.00 3.00 1.54 3.40 -6.325 .000
7 2.00 3.00 1.54 1.33 -6.349 .000
TOTAL -12.658 .000
0
5
10
15
20
25
30
35
40
1 2 3 4 1 2 3 4
BMR AMR
32
18
0 0 0 0
33
17
29
21
0 0 0 0
37
13
23 27
0 0 0 0
30
20 23
27
0 0 0 0
35
15
0 0 0 0 0 0 0 0
Group 4 Group 5 Group 6 Group 7
36
Table 12 shows whether there is any significant difference exist between the
four outcome groups based on manifestation of the cognitive feature was shown based
on the number of children. And there was no much statistically significant difference
between each age groups seen even-though the number of children in each group with
specific features were different.
Table 12: Correlation of children with manifestations of different cognitive
features
N P CHI
SQUARE
VALUE
P
VALUE
Test 1 109 91 .121 .777
Test 2 99 101 .084 .779
Test 3 99 101 0.00 1.00
B-Both
features
C-
Centration
E-
Egocentrism
X-
absence
of both
features
CHI
SQUARE
VALUE
P
VALUE
Groups
based on
cognitive
features
75 33 37 55
.463
.927
37
DISCUSSION
Child psychology is an intricate area, explains how people change as they
grow up from birth to adolescence mapping children‟s physical, cognitive, social and
emotional development.36
Cognition refers to mental activities involved in
acquisition, processing, organization, & use of knowledge.37
And it explains how a
child, who is cognitively zero at birth acquires knowledge throughout the life which
endorses that children are not just miniature adults. In our perspective, cognition is the
most important and most required science of psychology for paediatric dentist
because it will give him an exact idea of limitation of child‟s capability to
accommodate the challenges of the dental treatment so he does not tax the child
beyond his mental capacity as Childs behavior pattern is governed by various levels
of development, such as physical, emotional, intellectual and psychological factors4 it
becomes imperative for a pediatric dentist to understand every stage of cognition and
apply it relevantly to situations.
Jean Piaget, the most influential theorist in the study of cognitive
development5 provides the foundation on which constructionist theories are based.
Through his studies he explained how a child develops from zero level of
understanding to a fully developed child. It was his continuous experiments which
made the foundation for the cognitive development in a child. Children can be often
referred to a white paper in which they built on new schemas and extend their data
through experimenting the world and by assimilation, accommodation and
adaptation39,40
and the combined process of assimilation and accommodation increase
cognitive growth and maturation intellectually, socially, morally, and emotionally
eventually by processes of organization, adaptation, and reflective abstraction which
38
plays important roles in children‟s development. He also explains that children do not
passively absorb structures from the adults and other people around them, they
actively create their own accommodations and so construct their own understandings.
In cognitive development, as individual schemes adapt, larger cognitive structures
emerge and change. When these larger schemas are modified and reorganized, new
and more powerful ways of thinking become possible. Children possess limited level
of cognition and understanding to their age and perceiving this cognitive
development, pedodontist can frame suitable behavior management strategy
according to their level of cognition and can help mold them in their own world of
knowledge which can reduce the use of complex strategies in the clinical setup. In
studying the cognitive development of children and adolescents, Piaget identified four
major stages: sensorimotor, preoperational, concrete operational and formal
operational. Piaget believed all children pass through these phases to advance to the
next level of cognitive development.41
In each stage, children demonstrate new
intellectual abilities and increasingly complex understanding of the world.
This study is first of its kind and it is of importance to the present generation
as Piaget‟s study was done 6 decades ago and children of present generation are
different from the generation in which he had done the study which makes us to take a
call to study the cognition of present generation and to apply it to dental scenario.
Thus, our study aims at studying the cognition of the present generation of children
and to clinically apply these features in behavior modification by forming a new
behaviour management strategy (named Amelioration) to make the child feel
comfortable and thereby instills a positive attitude in them.
39
Our study results can be discussed under the following headings:
Intendment on the age group selection
Process of cognition
Stages of cognition
Preoperational cognitive stage
Three tests used to study cognition
Practical application of features of stages of cognitive development at an age
group of 4 to 7 years of preoperational stage as a behavior management
strategy
Intendments on the age group selection:
Our study sample consisted of children under the category of preoperational
stage of child psychology with the age range of 4 to 7 years. This is the age when the
understanding level of child starts to grow through intricate stages and develop
intellectual abilities42
and a better foundation formed at this stage can tailor make the
child to build a strong positive dental attitude in them since in cognitive development,
there is always a continuous progress from spontaneous actions and reflexes towards
desirable habits and intelligence. It is also the period of time when first-time child
comes to a dentist as their first appointment mostly due to the consequences of early
childhood caries. Hence this becomes an important age group and if not treated at this
age, can worsen the situation. Hence the management of the child in a better and
positive way is mandatory to promote the child and create child friendly atmosphere
which can be attained by the proper behavior management strategy by the Pediatric
dentist thereby instills a positive dental attitude. This is the age range where high
caries prevalence is seen according to the studies done by Eissa Al-Hosani and
40
Andrew Rugg-Gunn (1998)43
; Julie M W Tang et al (1997)44
; Norman Tinanoff et al
(2002)45
; which is in accordance with our study. The selection of this age group of
preoperational stage is in par with the previous studies by Giovanni Delitala (1996) 9
;
Gunilla Klingberg & Anders G. Broberg (2007)46
; Ashokan et al (2014)13
; where they
gave the similar scenario in children manifesting with typical cognitive features.
Process of cognition:
In this study, Preoperational stage of cognitive development between the 2
years to 7 years of age was included. It is the second stage of cognitive development
during which children think symbolically about objects, but reason is based on
appearance rather than logic.47
This period includes pre-conceptual (2-4 years) and
intuitive stage (4-7 years). Pre-logical reasoning appears in the intuitive stage.
Piaget‟s second stage, preoperational thought, features the flourishing use of mental
representations and the beginnings of logic (intuitive thought). Although logic is
emerging, it isbased only on personal experience (Piaget called it intuitive). Children
still do not recognize that some logical processes can be reversed. The child begins to
construct more complex images and more elaborate concepts and these intuitive stage
children could be difficult to behavior manage whose Intelligence is egocentric and
intuitive, not logical. The characteristic features common in this age group, includes
egocentrism and centration. In our study the presence or absence of the characteristics
among these 4-7 years old children was assessed in percentage values and
comparison of the prevalence was done among the children based on their age groups
and the study presented egocentrism in 94 % children of 4 years,42 % of children of 5
years, 48 % of children of 6 years and 34 % of children of 7 years as well as
centration in 69% in age 4, 45% in age 5& 6 and 39% in age 7 children and this
41
finding was in accordance with the study done by, Flavell, J. H (1992)47
; Sharath
Ashokan et al (2014)13
; Van der Maas, H. L, & Molenaar, P. C (1992)48
; Doise W,
Mugny G (1979)49
; Piaget J (1964)38
; where they provided the similar finding of
manifestation of egocentrism and centration in 4 to 7 year age group of children.
Egocentrism is the preoperational cognitive feature wherein children view the world
subjectively, in a special, self- centered way and child believes that his or her point of
view is the only one and finds it difficult to put himself in the place of another person.
Centration or centering is the feature where the child focuses on the most important
characteristic of what he or she sees, excluding everything else and his reaction or
comprehension of an object or situation is based on the most compelling and striking
feature of the stimulus.
Stages of cognition
Cognitive theory concerns the developmental stages of child cognition.
Describing the stages of cognitive development with an emphasis on their importance
to pediatric dentistry provides suggestions for treatment planning and behaviour
shaping. Each stage represented characteristic features and the four primary stages of
development are: sensorimotor, preoperational, concrete operational, and formal
operational. The stage with which we deal in the present study is preoperational stage
where characteristics of this stage include an increase in language ability (with over-
generalizations), symbolic thought, egocentric perspective, centration, animism,
constructivism, structuring, and limited logic.32
The other stages are: Sensorimotor
stage which starts from birth up to 2 years of age where infants and toddlers “think”
with their eyes, nose, ears, and hands and in other words, they use their senses to
think.50
The third stage is called the concrete operational, and this lasts from ages 7 to
42
11 where the child begins to perform logical reasoning, understand logic to solve
certain problems, but problems should have concrete solutions.10
In the previous
stage, a child only understands logical functions without abstract thinking. In the final
stage of formal operation, a child begins to understand abstract ideas often called
hypothetical thinking.
We selected the age group of preoperational stage of children as our study
mainly aims at their characteristic features of egocentrism and centration.
Preoperational cognitive stage
Our study evaluated how far the phenomenal stages of egocentrism and
centration were applicable to the present generation and in all the age groups we
found that in comparison to previous study by Piaget, this study showed more
expression in the age group of 4 years and it decreased as the child grew from 4 to 7
years and their finding was in comparison to the previous study by J Piget (1963)51
; G
Delitala (1996)9; Inhelder et al (1956)
52; Borke (1975)
53; Kenneth H Rubin (1973)
8;
and S Ashokan et al (2014)13
. The manifestation of most prominent striking
psychological feature in different age groups were shown different. The feature
egocentrism in which the child cannot understand one‟s point of view and centration
where the child focus on the most striking feature of the situation were explained with
the help of the 3 basic experiments. Presence of egocentrism and centration features
in age four children can be explained to their stage of cognitive development. Some
like Feffer (1959)54
; Piaget J (1950)55
, have identified the factor as „the inability to
decenter,‟ that is, the child‟s inability to shift his attention from one aspect of an
object or situation to another. They are very poor in understanding another person‟s
point of view as well as they are poor in differentiating the appearance and
43
concentrates on only the most striking feature in this age. And here in this study, we
can see that as the age increases, the presence of these feature seems to be reducing in
children and some possess none of these features as they move through the age of
five, six and seven. This can be said on the basis of their intelligence development or
cognitive development. The children of this era or generation exhibit more IQ than
the children of older generation explained by Piaget based on his theories which was
put forward 60 years ago for same age groups where he presented the manifestation of
features in an age range of 4 to 7 years. Our study stands different in this aspect where
we tried to find which specific age group showed better manifestation of the feature
and found the relation of age and cognitive features. There seems to be a sequential
growth of cognition in yearly basis than what Piaget had found in range of 4 to 7
years.
Three tests used to study cognition
Cognitive development stage in the present study with the help of prominent
features like egocentrism and centration in each child was tested based on three
experiments such as Policeman doll test for egocentrism and classical beaker test &
coin test for centration principle. The tests commonly used was 3 mountain test which
was Piaget‟s original test of egocentrism, but we selected the Policeman doll test
since this test pointed towards better understanding by the children so that their
cognitive development is appropriately disclosed. The test called “Policeman doll
test” in which Hughes (1975)56
tested egocentrism using a model of two intersecting
walls, a doll of a little boy and two „policeman‟ dolls. To familiarize the child with
the task, one of the policemen is placed somewhere in the model and the child is
asked to hide the boy where the policeman cannot see him (the walls are too high for
44
the policeman to see over). If the child makes any mistakes these are pointed out and
it is allowed to try again and in the test proper the second policeman is introduced and
the child is asked to hide the doll where neither of the policemen can see him. Hughes
found that pre-school children selected a correct hiding place for the boy 90% of the
time. Even the youngest children in the sample (3 1⁄2 to 4 years) got it right 88% of
the time. In other words, children select views based on their own personal and
intuitive experience with the scene. They don‟t yet take into account the logical
necessity that someone viewing the scene from a different place will have a different
perspective. (McLeod, S. A ;2015).57
When we used both these tests to see which is
more appropriately disclosing the cognitive development of a child and at the same
time comfortable for the child, Policeman doll test was liked by most of them because
this test provides better view and understanding for the child than the three mountains
test, hence we considered using this test for our study. In case of 3-mountain test,
child is shown a three-dimensional model of three mountains of different sizes and
colours and different features (e.g. a cross, a house, some snow). After the child has
had an opportunity to explore the model, a doll is introduced and is placed so that it is
„looking‟ at the model from a different position from the child‟s. The child is asked
what the doll can see, and indicates its answer by choosing one from a range of
pictures, each showing the mountains from a different point of view. (Piaget &
Inhelder, 1948/1956).58
The other tests used were classical beaker teat and coin test which is based on
the centration principle where the child can focus only on the most striking feature of
the situation. In beaker test, there will be 2 beakers with same amount of water and
second beaker empties into a taller beaker. When the child was asked which beaker
45
contains more water, the child usually points the taller beaker since the child only
focuses on the length of the beaker rather than the volume it contained. Similarly, the
arrangement of coins in a longer and shorter raw also shows the centration principle
since the child focuses only on the length of the raw. All these three tests gave us the
state of child‟s cognitive development on which we can modify their behaviour
accordingly to be implemented in a clinical setup.
Practical application of features of stages of cognitive development at an age
group of 4 to 7 years of preoperational stage as a behavior management strategy
This is the first study done with an innovative intention of gaining better
behavior management by applying the basic stages of development of cognition as
explained by Psychologists. It is being shown that children exhibit typical features in
different stages, hence understanding the phenomenal behaviour pattern & cognition
and applying that particular level to tailor make behaviour modification strategies can
make a paradigm shift in the child cooperation. Thus, the second part of our study
focused on the implication of egocentrism and centration and essentially applying
novel behaviour management strategies (named as Amelioration) appropriate for
these procedures.
Piaget explained in the age of 4 to 7 years, the most prominent feature seen are
egocentrism and centration. Psychological interventions are recommended for use in
managing children's procedural pain, and these interventions are typically cognitive-
behavioral in orientation. Our sample of children consisted only children who falls
under definitely negative and negative category on Frankl‟s behaviour scale to check
the possibility of shaping the children‟s behaviour into positive and definitely
46
positive. A number of literature reviews have highlighted the importance and value of
psychological interventions for reducing pediatric procedural pain and distress.
Therefore, we tried implementing these two main features of cognitive development
into behaviour modification to make it a novel behaviour management strategy.
In case of centration, children usually cannot focus on more than one aspect at
a time. In pediatric practice injections provoke highest fear and anxiety as child‟s
perception and attention is on procedure so pain perception is more leading to
behavioral crisis. In our study, we planned to practically apply the feature of
centration and made use of the specifications of the dental chair and by asking the
patient to fill a cup with water from a three-way syringe so his attention is focused on
one aspect so he cannot concentrate on perception of pain which is a typical character
of centration. This task helps to focus child carefully accomplishing the task whereby
his anxiety and fear is masked over. We could make out the difference that children
undergoing our study becoming free of fear and their state of mind allows for carrying
out the proper dental procedure without any hindrance. This technique which is
similar to distraction method, we are en-caching on the process of centration.
Distraction is the key to practicing painless dentistry and here we tried to mold the
child by his cognition level of understanding the world. Providing the children with
strikingly colorful, friendly, relaxing environment to focus on can centrate them on to
the task given to them and distract them from the possibly “terrifying” instruments
present in a dental setting. Distraction studies are proven methods in behaviour
management techniques and our study was in accordance with the results of these
studies where distraction technique was successfully used by F. Guinot Jimeno et al25
;
Amal Al-Khotani, Lanre A‟aziz Bello
and Nikolaos Christidis26
; Nash,&Gamber
(1984)59
; and Venham et al (1981)60
. This study was in contrast with the study done
47
by Jennifer Creem Aitken et al in 200223
where they found that audio distraction was
not an effective means of reducing anxiety, pain or uncooperative behavior during
pediatric restorative dental procedures. Distraction in particular has been touted as a
key intervention for immunization pain in children of same age group in a study by
Schechter NL et al.61
We have also obtained the same results in our study but our
study is different and stands distinct because it clinically applied psychological
features into behaviour management to make it a new novel behaviour management
strategy.
In case egocentrism, the child cannot understand one‟s point of view, so the
child could be allowed to make believe he/she is the boss of the situation and is in-
charge and could be permitted to take some decision about the treatment, like child
was provided with a sound producing soft ball and asked the child to press it to give a
signal to the doctor when to stop or start the procedure, or using hand signals to
temporarily stop and start or allow them to be „in-charge‟ of the saliva ejector. We
named this new, novel behaviour management strategy which is based on the
cognitive development of the child as “Amelioration”. By using this method, the
child is left to feel as the boss of the situation by which his fear and anxiety levels are
reduced which in-turn helped us manage the patient better during the clinical
procedure. As stated by Giovanni Delitala in 20009, when children exhibiting
egocentric behaviour, therapy should be directed toward making them feel more
important and toward developing appropriate coping behaviour, which was
accomplished in our study. According to a study by Russ et al in199362
, both the
cognitive and affective components of children's play behavior promote the
development of adaptive functioning. Coping can be conceptualized as a kind of
practical divergent thinking ability that involves generating solutions to real-life
48
problems and he explains coping as "the cognitive or behavioral actions taken in the
course of a particular stressful episode" (Combpas, 1987).62
Bennett-Branson and
Craig (1993)63
found that adolescents used more cognitively based coping strategies
in response to pain compared with younger children. It was found that younger and
more anxious children expressed a greater need for behavioral coping strategies
according to Weinstein et al, 199664
and they postulated that a relationship existed
between the level of dental anxiety (Karjalainen et al, 2003)64
, previous pain
experience and the choice of coping strategy (Versloot et al, 2004).64
Our study is in
accordance with the study done by Lawrence J. Siegel and Lizette Peterson (1980)65
,
which stated that coping skills reduces anxiety which supported our result that coping
reduces stress in children during a clinical procedure.
Clinical application of these psychological features into behavior modification
provided us with modified child‟s behaviour which rated either 3 or 4 of Frankl‟s
behaviour rating scale which points towards a better cooperating child behaviour from
a definitely negative or negative behaviour. Here we tried to utilize the particular
prominent psychological feature into behaviour modification by which the child is
moldable in his own world of understanding and he understands the situation and
cooperates well to the procedure. Our main success in this study is that there are no
literature entry correlating this cognitive growth to behaviour management. We tried
to specifically implement these features for a particular group of children who are
definitely negative and negative based on Frankl‟s behaviour rating scale. So, the
behaviour modification technique which is appropriate for the exact cognitive state of
the child is more appropriate.
Our study showed that behaviour of the children which was definitely negative
and negative according to Frankl‟s behaviour rating scale66
, was changed into positive
49
and definitely positive in all the age groups. The most promising results were seen
comparatively more in age 6 but age 4 and 5 also showed relative results accordingly
at p value < 0.001 (mean value of 3.40, 3.34 and 3.26 at age 6, 4 & 5). Even though
Age 7 showed better behaviour modification into positive, but comparatively less
number of children could be modified based on these techniques since all of them
didn‟t show the psychological features for that age (mean score of 1.33). According to
the chi-square statistical test performed, the behaviour modification was significant
with proper psychological feature based methods used in children for each specific
group. The test value before behaviour modification was 0.182 which shifted to 0.489
after the use of behaviour modification at p<0.001. The techniques used for behaviour
modification was highly statistically significant at p value < 0. 001 for all the age
groups based on the Wilcoxon Signed Ranks Test.
Hence, by the end of the study, we could come to a conclusion that clinical
application of these psychological feature based behaviour modification techniques
are the best method which can completely understand the child and a statistically
significant behaviour modification results have been found, suggesting psychological
feature based behaviour modification can be used as a novel and pioneer behaviour
management strategy named “Amelioration” for better patient cooperation.
50
CONCLUSION
Within the limitations of the study, the following conclusions can be made:
Child psychology and cognitive developments are the unavoidable part of a
child’s development and to understand the cognitive development is
indispensable for all the Pediatric Dentists as it gives an edge over limitations
of the child’s capability to accommodate the challenges of the dental treatment
so that the child may not be taxed beyond his mental capacity.
Our study evaluated the manifestation of pre-operational cognitive features
like egocentrism and centration which were found mostly in age four children.
The least number of children manifesting with cognitive features were seen in
age 7, drawing to a conclusion that the manifestation of cognitive features
decreased as the age increased from 4 to 7 years.
Psychological feature based behaviour modification strategy was used
appropriately for each child based on cognitive stage which were proven to be
better option in managing the child patient in a clinical setup.
A new and novel behaviour modification strategy was formulated named
Amelioration for better patient management.
51
SUMMARY
The intricate field of child psychology explain the cognitive developments in a
child from birth till adolescence emphasizing on the dramatic changes which
takes place where children evolve through definite stages of intellectual,
physical, mental, emotional and cognitive development.
Cognition is the most important science of psychology which explains how a
child, who is cognitively zero at birth acquires knowledge in his/her life through
the processes of acquisition, processing and organization thereby he develops
into an intelligent adult with innumerable information, endorsing that children
are not just miniature adults and every event makes a huge impact on his
cognition. Based on the cognitive ability of a child, we here introduced a
pioneer and novel behaviour management strategy named as “Amelioration”.
In our perspective, understanding the cognitive development of the child is
incredibly essential for paediatric dentist as it gives an idea on the capabilities
and limitations of child’s mental capability to accommodate the challenges of
the dental treatment so that the child may not be taxed beyond his level of
coping in the dental setup which could otherwise lead to dental anxiety and
phobia if not handled appropriately.
This present cross-sectional study is first of its kind where we evaluated whether
the psychological features explained by Jean Piaget six decades ago for the child
in preoperational stage of 4 to 7 years, including egocentrism and centration are
still valid in the present generation of children and then to apply these features
for behavior modifications as a new behaviour management strategy.
52
The study was conducted among 200 children, divided into four age based
groups of 4, 5, 6 & 7 years with 50 children in each group. Manifestation of
phenomenal stages of cognitive principles in each child was assessed by three
experiments including Policeman doll test, concept of cardinal numbers based
on centration principle, and classical beaker experiment and we compared the
finding and it was found in contrast to the finding of Piaget that cognition in
children of present generation was more and there was sequential growth of
cognition in yearly basis in children.
First part of our study highlights the prevalence of egocentrism and centration
in children of 4 years which gradually decrease with increasing age of the child
up to 7 years, in comparison to previous study by Piaget who generalized these
features for the age range of 4-7 years.
The decrease in the manifestation of cognitive feature between the different age
groups can be explained on the basis of their intelligence or cognitive
development. The children of the latest generation exhibit more cognition where
their brain is fed with numerous stimuli which improves the cognitive
capability, than the children of older generation studied by Piaget on the basis of
which he had put forth the theory 60 years ago for children in an age range of 4-
7 years. In contrast to this, our study establishes a sequential growth of
cognition on a yearly basis so that within the proposed age range itself the
prevalence of features varies.
The next level of our study emphasizes more on the clinical implications of
egocentrism and centration where essential application of cognition based
behaviour management strategy for each child so as to mold the child in his own
world of understanding was made during clinical procedures.
53
Egocentrism is the inability to take another person’s perspective or point of
view. It is the assumption that others view the world as one does oneself. In the
clinical setup, the child is made to feel as the boss of the situation where he is
provided with a squeeze toy which make sound and is to give the doctor a signal
to stop or start the procedure and we called this novel and new behaviour
modification strategy where we modified the behaviour of the child with the
help of his cognitive ability is modified and named it as “Amelioration”. So, the
child feels he has total control on the situation and avoid panic associated with
dental phobia.
Centration is the tendency to focus, or center, on only one, most striking or
compelling aspect of the situation and ignore other aspects of the situation. In
the clinical setup, the child is made to concentrate on the task given to him such
as filling water in a glass using 3-way syringe which distracts him from the
dental procedure and diverts his mind so that he is fully concentrated in
achieving the task.
Here we tried two different cognition based behaviour management strategies
which provided better patient cooperation and we named it as “Amelioration”.
This clinical application of egocentrism and centration based behavior
modification provided us with an improved, positive behaviour in children who
were initially rated either 3 or 4 according to Frankl’s behaviour rating scale
(negative and definitely negative behaviour).
Hence, thorough understanding of the cognition of each child should be gained
by every Pedodontist so that behaviour modification strategies can be tailor-
made for the child in the clinical set up so as to instill a positive dental attitude.
54
Our study concludes that cognitive feature based behaviour modification
techniques (Amelioration) are the best method which is practically applicable
for eliciting a cooperative response from the child by understanding the
psychology and cognitive development of the child and it can be considered as a
novel and pioneer behaviour management strategy for better patient cooperation.
55
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59. Stark LJ, Allen KD, Hurst M, Nash DA, Rigney B, Stokes TF. Distraction: Its
utilization and efficacy with children undergoing dental treatment. Journal of
Applied Behavior Analysis. 1989 Sep 1;22(3):297-307.
60. Bradford R. The Importance of Psychosocial Factors in Understanding Child
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Psychiatry. 1990 Sep 1;31(6):973-82.
61. Schechter NL. The undertreatment of pain in children: an overview. Pediatric
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during invasive dental procedure. Journal of Clinical Child Psychology. 1996 Jun
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65. Siegel LJ, Peterson L. Stress reduction in young dental patients through coping
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patient. Pediatric dentistry. 2008;30(7 Suppl):125.
63
64
65
66
67
68
PROFORMA PROTOTYPE
Name of the patient: Age / sex:
PDT: BT:
CT:
a) BEHAVIOUR OF THE CHILD BEFORE THE START OF PROCEDURE:
FRANKL’S BEHAVIOUR RATING SCALE
RATING BEHAVIOUR RATING FOR
CHILD
PATIENT
UNDER
TRAETMENT
1. Definitely
negative
Refusal of treatment, crying forcefully, fearful, or any
other overt evidence of extreme negativism
2.Negative Reluctant to accept treatment, uncooperative, some
evidence of negative attitude but not pronounced,
sullen, withdrawn
3.Positive Acceptance of treatment, at times cautious, willingness
to comply with the dentist, at times with reservation
but patient follows the dentist's directions
cooperatively.
4.Definitely
positive
Good rapport with the dentist, interested in the dental
procedures, laughing and enjoying the situation
69
b) BEHAVIOUR OF THE CHILD AFTER THE APPLICATION OF
BEHAVIOUR MANAGEMENT TECHNIQUE:
FRANKL’S BEHAVIOUR RATING SCALE
RATING BEHAVIOUR RATING FOR
CHILD
PATIENT
UNDER
TRAETMENT
1. Definitely
negative
Refusal of treatment, crying forcefully, fearful, or any
other overt evidence of extreme negativism
2.Negative Reluctant to accept treatment, uncooperative, some
evidence of negative attitude but not pronounced, sullen,
withdrawn
3.Positive Acceptance of treatment, at times cautious, willingness to
comply with the dentist, at times with reservation but
patient follows the dentist's directions cooperatively.
4.Definitely
positive
Good rapport with the dentist, interested in the dental
procedures, laughing and enjoying the situation
70
MASTER CHART
Sl
No
Group
1=age
group
Age Sex
Test
1=
PDT
Test
2=
BT
Test
3=
CT
Group 2:
E=EGOCENTRISM;
C=CENTRATION;
B=BOTH;
X=NOTHING
BMR:
1-4
AMR:
1-4
1. 4 4 F N N N B 2 3
2. 4 4 M N N N B 2 4
3. 4 4 M N N N B 2 4
4. 4 4 F N P P E 2 4
5. 4 4 F N P P E 2 4
6. 4 4 F N N N B 1 3
7. 4 4 M N P P E 2 3
8. 4 4 M N N N B 2 3
9. 4 4 F N N N B 2 3
10. 4 4 M N N N B 1 4
11. 4 4 F N P P E 1 4
12. 4 4 M N P P E 2 4
13. 4 4 M N N N B 2 3
14. 4 4 M N N N B 1 3
15. 4 4 M N N N B 1 4
16. 4 4 F N N N B 1 3
17. 4 4.5 M N P P E 1 3
18. 4 4 M N N N B 1 4
19. 4 4 F N N N B 2 4
20. 4 4 M N N N B 2 4
21. 4 4 F N N N B 1 4
22. 4 4 F N P P E 1 3
23. 4 4 M N N N B 1 3
24. 4 4 M N N N B 1 3
25. 4 4 M N N N B 1 3
26. 4 4 F N N N B 1 3
27. 4 4 M N N N B 2 4
28. 4 4 F N P P E 1 3
29. 4 4 M P P P X 1 3
30. 4 4 F N P P E 1 3
31. 4 4 M N N N B 1 3
32. 4 4 M N N N B 1 3
33. 4 4 M N N N B 1 3
34. 4 4 M N P P E 2 3
35. 4 4 M N P P E 1 3
36. 4 4 M N N N B 2 3
37. 4 4 M N N N B 1 3
38. 4 4 M P P P X 1 3
71
39. 4 4 M P N N C 1 3
40. 4 4 M N N N B 1 3
41. 4 4 F N N N B 1 3
42. 4 4 M N N N B 1 4
43. 4 4 F N N N B 1 3
44. 4 4 M N N N B 2 3
45. 4 4 M N N N B 2 4
46. 4 4 M N P P E 1 4
47. 4 4 F N P N B 2 3
48. 4 4 F N N N B 1 4
49. 4 4 F N N N B 1 3
50. 4 4.5 F N P P E 1 3
51. 5 5 F N N N B 2 4
52. 5 5 F P N N C 1 3
53. 5 5 F P P P X 2 4
54. 5 5 M N N N B 2 4
55. 5 5 M N P P E 2 4
56. 5 5 F N N N B 2 3
57. 5 5 F N N N B 1 3
58. 5 5 M P P N C 2 3
59. 5 5 F N N N B 2 4
60. 5 5 F P N N C 2 3
61. 5 5 F N N N B 1 3
62. 5 5 F P P N C 2 3
63. 5 5 M N N P B 1 3
64. 5 5 F N P P E 1 3
65. 5 5 M P N N C 1 4
66. 5 5 F N P N B 1 4
67. 5 5 F N N N B 1 3
68. 5 5 M N P P E 1 3
69. 5 5 M P P P X 2 4
70. 5 5 F N N P B 1 3
71. 5 5 M P N N C 1 4
72. 5 5 M P P P X 1 3
73. 5 5 M N N N B 1 3
74. 5 5 F N N N B 1 3
75. 5 5 F P P P X 2 3
76. 5 5 F N P P E 1 4
77. 5 5 F P P P X 2 3
78. 5 5 M P P P X 1 3
79. 5 5 F N P P E 1 3
80. 5 5 M N P P E 1 3
81. 5 5 M N P P E 1 3
82. 5 5 M N N N B 2 3
83. 5 5 F P N N C 1 3
84. 5 5 M N N N B 2 3
72
85. 5 5 M P P P X 1 3
86. 5 5 M P P P X 2 3
87. 5 5 M P N N C 1 3
88. 5 5 F P P P X 1 3
89. 5 5 M P P P X 2 3
90. 5 5 M P P P X 1 3
91. 5 5 M P P P X 1 3
92. 5 5 M P N P C 2 4
93. 5 5 F P P P X 1 3
94. 5 5 M P P P X 2 3
95. 5 5 M P P P X 1 4
96. 5 5.5 M P N N C 1 4
97. 5 5 F P N P B 2 3
98. 5 5 F P P P X 2 3
99. 5 5 F P P N C 1 3
100. 5 5 M P N P B 2 3
101. 6 6 M P P P X 1 3
102. 6 6 F P P P X 2 4
103. 6 6 M N N N B 1 3
104. 6 6 F P P P X 1 3
105. 6 6 F N N N B 2 4
106. 6 6 F N N N B 2 3
107. 6 6 M P P P X 2 4
108. 6 6 F P P P X 1 4
109. 6 6 F N P P E 2 4
110. 6 6 F N P P E 2 3
111. 6 6 F N P P E 2 4
112. 6 6 F N N N B 2 4
113. 6 6 F N N N B 1 3
114. 6 6 F P P P X 2 4
115. 6 6 F N P P E 2 4
116. 6 6 M P P P X 2 4
117. 6 6 F N N N B 1 3
118. 6 6 M N N P B 1 4
119. 6 6 F N N N B 1 3
120. 6 6 M N N N B 1 3
121. 6 6 F N N N B 1 3
122. 6 6 F P P P X 2 4
123. 6 6 F N N N B 2 3
124. 6 6 F N P P E 1 3
125. 6 6 F P P P X 2 4
126. 6 6 M P P P X 1 4
127. 6 6 M P N N C 2 3
128. 6 6 F P P P X 2 4
129. 6 6 F N P P E 2 3
130. 6 6 F P P P X 2 3
73
131. 6 6 M P N N C 1 3
132. 6 6 M N P P E 2 3
133. 6 6 M N P P E 1 3
134. 6 6 F P N N C 2 3
135. 6 6 M N P P E 1 3
136. 6 6 F P P P X 1 4
137. 6 6 M N N N B 1 4
138. 6 6 F P N N C 2 3
139. 6 6 F N N N B 1 3
140. 6 6 F N N N B 1 3
141. 6 6 F P N N C 2 3
142. 6 6 M N N N B 2 3
143. 6 6 F P N P B 1 3
144. 6 6 M P P N C 1 4
145. 6 6 F P N N C 2 3
146. 6 6 F P N P C 2 3
147. 6 6 M P N P C 2 4
148. 6 6 F P P P X 1 3
149. 6 6 F P P P X 2 3
150. 6 6 F P P P X 1 4
151. 7 7 F P N N C 2 4
152. 7 7 F P N N C 1 3
153. 7 7 F P P P X 2 3
154. 7 7 M P P P X 1 3
155. 7 7 F P P P X 2 4
156. 7 7 M P N N C 2 4
157. 7 7 M P N N C 2 4
158. 7 7 F N N N B 2 3
159. 7 7 F N N N B 2 3
160. 7 7 M P N N C 2 4
161. 7 7.5 M P P P X 1 3
162. 7 7.5 M N N N B 1 3
163. 7 7 M N N N B 2 3
164. 7 7 M N P P E 2 4
165. 7 7 M P N N C 1 4
166. 7 7 M P P P X 1 3
167. 7 7 F N N N B 2 3
168. 7 7 M P P P X 2 4
169. 7 7 F P P P X 1 3
170. 7 7 F N N N B 2 3
171. 7 7 M P N N C 1 3
172. 7 7 M P P P X 2 3
173. 7 7 M N N N B 2 3
174. 7 7 M P P P X 2 3
175. 7 7 M N P P E 1 3
176. 7 7 M P P P X 2 3
74
177. 7 7 M N P P E 2 4
178. 7 7 M N P P E 1 3
179. 7 7 M P N N C 1 3
180. 7 7 M P P P X 1 3
181. 7 7 M P P P X 1 3
182. 7 7 M P P P X 2 4
183. 7 7 F P P P X 2 3
184. 7 7 F P P P X 1 3
185. 7 7 F N P P E 2 3
186. 7 7 M P P N C 1 3
187. 7 7 M P P N C 1 3
188. 7 7 F P P P X 1 3
189. 7 7 M N N N B 1 3
190. 7 7 M N P P E 2 3
191. 7 7 F N P P E 1 4
192. 7 7 M P P P X 2 4
193. 7 7 M P P P X 1 3
194. 7 7 F P P P X 1 4
195. 7 7 M N P P E 1 4
196. 7 7 F P N N C 2 3
197. 7 7 F P P N C 2 3
198. 7 7 F P P P X 2 3
199. 7 7 M P P P X 1 3
200. 7 7 M N N N B 2 4
Group 1: age based group
Test 1: PDT=Policeman doll test; N=Negative=Egocentric, P=Positive= Non- Egocentric
Test 2:BT= Beaker Test; N=Negative=Centrated, P=Positive= Non- Centrated
Test 3: CT=Coin test; N=Negative=Centrated, P=Positive= Non- Centrated
Group 2: Manifestation of Cognitive feature present
BMR: Behaviour of the child before the start of the procedure
AMR: Behaviour of the child after the application of behaviour management strategy
Dr. DHANYA K B
75
ANNEXURES/PHOTOS/IMAGES
Figure 1: Schematic Representation Of Policemann Doll Test
(Cerdit: Hughes, M. (1975). Egocentrism in preschool children. Unpublished doctoral
dissertation. Edinburgh University)
Figure 2: Model prepared - The Policemann Doll Test For The Conduction of
The Study
76
Figure 3: Child Performing Policaman Doll Test
Figure 4: Child Performing Policaman Doll Test
77
Figure 5: Schematic Representation Of Beaker Test
Credit : http://info.thinkfun.com/stem-education/milestone-series-cognitive-
development
Figure 6: Child Performing Beaker Test
78
Figure 7: Schematic Representation Of Coin Test
Credit:
:https://www.google.co.in/imgres?imgurl=https%3A%2F%2Fi.ytimg.com%2Fvi%2F
YtLEWVu815o%2Fhqdefault.jpg&imgrefurl=https%3A%2F%2Fwww.youtube.com
%2Fwatch%3Fv%3DYtLEWVu815o&docid=6LhoZzSp9LRBwM&tbnid=NAGzRQ
Q54UJjPM%3A&vet=10ahUKEwialM2grdHXAhXBP48KHWH5AiIQMwhBKAQw
BA..i&w=480&h=360&client=safari&bih=772&biw=1311&q=coin%20test%20of%
20preoperational%20stage&ved=0ahUKEwialM2grdHXAhXBP48KHWH5AiIQMw
hBKAQwBA&iact=mrc&uact=8
79
Figure 8: Schematic Representation of Coin Test
Credit:
https://www.google.co.in/imgres?imgurl=https%3A%2F%2Fi.ytimg.com%2Fvi%2F
GLj0IZFLKvg%2Fhqdefault.jpg&imgrefurl=https%3A%2F%2Fwww.youtube.com%
2Fwatch%3Fv%3DGLj0IZFLKvg&docid=z6uoDxEhkOrnbM&tbnid=V3sIWXB0Nt
PRM%3A&vet=10ahUKEwialM2grdHXAhXBP48KHWH5AiIQMwg_KAIwAg..i&
w=480&h=360&client=safari&bih=772&biw=1311&q=coin%20test%20of%20preop
erational%20stage&ved=0ahUKEwialM2grdHXAhXBP48KHWH5AiIQMwg_KAIw
Ag&iact=mrc&uact=8
80
Figure 9: Behaviour Management Using Egocentrism Termed As Amelioration.
81
Figure 10: Behaviour Management Using Centartion Termed As Amelioration.
