AUTHORTITLE

SPONS AGENctFOB DATENOTE,

DESCRIPTORS

ABSTRACT

Klorman, Rafael ; And' OthersA Further Assessment_ cf PrediBehavior in 'Dental T-reatment."Rochester Univ., Na l. Cell, of7ff13p.

Ors of- the hild es

Arty and c ces.

110-$0.83 BC-$1.67. duo toRst6ge.4 *Anxiety; *Childhood Attitudes; *Childien; -Dental

Evaluation ; *Dentistry; Elementary School -StddemtEvaluatiOn Methods; Mothex-Attitudes; .*Pteittcr-VariableS; *Reacive Behavior; Research

hin study examines t-he relgticnslip betweenchildren's disruptiveness during dental treatment and their state(comptOmpotneous or situational nervousness), trait /generalnervousness}, and specific dental anxiety. All patients studied wereabout 8 years old. Sample' .I (84, pedadcntic patients) unde;tent avariety of dental procedures (extracticins, restorations., etc.) On theday of ievaluation. Sample, II (48 pedodcrtic patients) underwent. adental restoration. Subjects in both,tiese samples weregassessedwhile under treatment for a procedure they undergone in -the past.Sample III donl,itted of 49 inexperienced ta\tients -who.were studied-during their farst dental restoration or, extraction. Eeforetreatment, the patient's fear of dentistry was fated by his motherand the dentist. Children's self-,reports of dental anxiety were, alsocorrelated with the data analysis. Results indicated c ;ly a sightrelationship between behaiiioral and, self-report measures of ,dentalanxiety with the -various predictor variatles,, and the child's.behavior during treatment could not be predicted from any. aspect ofmaternal anxiety. Findings suggest that the child' s anxiety towardsdental treatment is complexly determined, and that futt-re researchshould rclude multiple measures of assessment. (Authcr/C14)

* * * * * * * * * * * * * * * * * * **Reproductions suppli

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tes DE,PARTMENT OF HEALTH,EDUCATTIONA, WELFARENATIONAL INITITUTEOF

EDUCATION

THIS DOCUMENT HAS BEEN REP 6',, r.DUCED E*ACTLY AS RECEIVED FROMTHE13ER5ON OR ORGANIZATIONATIN0,110POIN TS OF vIEW ORDRiNIONSSTATED DO NOT NECESSNROLN: E EPRE-SENT OF FICIAL NATIONAL !WI TULE OFEDUCATION roSITtoN OR ,POLICY

/A Further Assessment 0 Pre ictors of

--i

BehaVibr in Denta Treatmentf,

e Child - '.s

fael iUd man, Robin M ch Pamela

University of Ochester

and Odd B. veer',

Eastman Dental Center

Rochester, N. 14627

iilpert,

Short title: Predictors of Child's Behavior

This research was suppo

0

ted by a. grant fro the

Roche p ychiatiric 'Service Insti_ute to the first./-

,

author. Computer time was fund by the College of

Arts and Science of the University of Rochester.'r)

We acknowledge the gracious cont butions to the

research of Drs. Barbara Melamed Stephen Adair;

the staff of Eastman Dental Cente and nuMeroup

-devoted undergrtduate assistants.9

"PE F1M111,1(1N 1(1 11E0'1

MAT I 111A I: I IiIHN

Iii it l- L III 1.(q1,1 Al_

iNFili-ONIA Two No (1,1:re N r H

11'f;Liv,7 III I11I, t

AND

The child's disruptiveness daring dental treatment was related

modestly t ,his age as well as-his state, trait, and dental anxiety. In three

samples comprising 132 experienced and 0 inexperienced pedodontic

patients, the child's behaviorduring treatment could not be predicted

from Qny aspect f maternal anxiety -- trait, state,or-dental. ,Prelhous

conceptions of maternal influence pn t child's dental anxiety shouldr--

be reevaluated.

Key Terms: State anxiety, trait nxiety ma ernal anxiety, uncoope a iveness,

pedodontics.

sses4nent of Predictors of the Child

,

Behav in Dental Treatment

A plethora of studies hve documented an association between pedodontic

1

patients uncoopera iveness the Initial treatment sassion and their mothers'

trait anxiety, i.e. general

Anxiety Scale.7

Ho

children with prier d'entaLtreStment.4'--8'4°

1-6rvousness, as assessed on the Taylor Manifest

ever, this relationship has not been replicated.among

4

A recent report9has suggeted that.this important theoretical question

might be clarified by separate consideration of both the patient's prior exper-1

ience in pedodontic treatment as\ well as various aspects of the patient's and

his mother's anxiety. Whereas Most previous research in this area has empha-\

sized trait anxiety, this work shOuld,aiso consider 4taie 4 xiety, i.e. ton-,

temporaneous or situational nervousness, .and specific dental anxiety. The

present paper is based on such an examination of two samples of experienced

pedodontic patients and one sample of inexperienced patients

Materials and Methods.

In Study 1,-there were 48 maleand 36 female pedodontic patients with

mean chronological age of 8.87 years (S.D. 2.01). These patients underwent

a variety of dental procedures on the day of evaluation, including extractions,

restorations; X-radiography, appliance adjustments, dental examinations, etc.

there .were 21 male and 27'female'pedodontic patients: with a me,an

age o-8.23 years (S-D. = 2-08) who underwent a dental restoration. Subjects, -

In thesetwo studies were aksessed while under treatment for a procedure that

.

they had undergone in the past. 'Study 3, there gpre 22 male and 27. female

,pedodontic patients with a Mean age of 8.21 years (S.D. e 2.20). These childret

ere studied during their first dental restoration or extraction. All subjects

were drawn from Eastman Dental Center, and subsets of the samples in Studies" 2

and 3 underwent modeling procedures a med,at reducing anxiety after being

A

nterviewed for the present research.

vlaw, the child' as asked o rate:verbally his nervousnessi.

In this 'in

at all.atrat4 5 = Very afraid)

situations selected by Melamed et al11

concerning eight

e subject also

hypotheticalidental41='

completed Venham'

Picture Test,12

a .forced-thoice projectiVe test Of state anxiety, as well As

the state and trait scales of Spielberger= -et -al's How I Feel. Questionnaire.

During dente treatment, the child's anxiouo..and disruptive behaviors were

13

. scored on Melamed et al Behavior ProfileScale.11 The judges' reliability.

14on this instrument are reported elsewhere-, Finally, at the conclusion of

treatment, the dentist rated the child's cooperativeness on Frankl,et al's -

15scale (1 = Definitely negative; 4 = Definitely positive)

Before treatment, the patient's fear ofdentistry wath rated.hy his mother

and dentist (1 = .Not at 11.afraid; 5 = Very afraid). The mother also completed

4e following. measureg: ) Wright and Alpern's Maternal Questionnaire, which

deals with the child's/ direct and vicarious experience with dental and medical

reatment. This scalle includes separate maternal ratings of both the child's

and the mother's on state anxiety, which were scored separately, as described

9previously-; 01 t e state and trait anxiety-scales of the Self Evaluation

16 17Questionnaire -.; c) Corah' Dental Anxiety Scale ; and (d) a paper-and-pencil

9 ,11ve on.offMelam al's scaleof dental anxiety, _which was administered

verbally too c dren.

Results

Rated and Oh erved Uncoo-erativeness

Table displays correlation coefficients between cooperativeness ratings

and the lent's age as7 well as several measures of the child's and mother's

anxiety Comparable data for the Behavior Profile observations appear in Table

2. A -hough cooperativeness t!nded to increase with age in each sample, this

re = tionship did not attain significance. The same trend was present -.for

BehaVior Profile adores and was significant for the experienced samples

Studies 1 and..

. Cooperativeness was associated with low levels of each of the three measures

of the childA

stote,anXiet. but.these correlations were significant only for

the How I Feel Seale in Stud 1. Ireontrast Behavior Profile c -fires Were not

significantly correlated with any measures of the child's state anxiety. In

turn,=_the patient'.s trait anxiety was correlated with Oneooperati-eness in

Studies 1 and 3 but did rick predict Behavior Profile

The meastires of the patient's dental anxiety were closely related to his

cores in any sample.;

ratedcooperativeness,du-ing treatment. This association vas significant forA'

the Maternal Questiorttre among the experienced samples of Studies 1 and 2.

NSimilarly, the patient's'vwn ratings of his fear of dentistry.pigni idantly

predicted his xated cooperat1veness. The c?mparable correlations between coopera-

tivenessan&the dentist''s pre-treaLant ratings of fear of dentistry are

probably'ldflated.by their reliance On two sets of `,judgments from the same person.-

tin the other and, the mother's ratings'of the child:s dental anxiety were

uncorrelated with his cooperativeness.

The associations bewteen the patient's dental anxiety and Behavior ProfileA

scores were not as strong. The Maternal Questionnaire t4as significantly correl-

ated with this measure of disruptiveness 'only_ in Study 1. Similarly, maternal`

'ratings of dental anxie were significantly associated with Behavior Profile

scores only in Stidy

Notably, meaSure_ maternal anxiety were inconsistently and largely non-.

significantly related to the child's behavior (luting treatment. The only extep-,

tions were the correlation between the. mother's ratingfof he state anxiety with.

low cooperativeness in-,Study 3, and the correlation between maternal dentalA

anxiety on Corah's scale with Behavior Profile scores in Study 2.

Tables .l

and 2

[able 3

The Child's Self-reports of Dental Anxiety .

Table 3 displays correlations between Melamed et al's scale of the.

child's dental anxiety and the other measures. disruptiveness during

treatment, the child's fear.of dentistry decreased with age,. but this

relationship was signifiCant only in Studyl. Measuies of state and trait

anxiety; as would be expected, were associated with highet reports of dental

anxiety,- 'although only three of the 12 coefficients involved achieved sign17-

correlation was present between the childficance. A 50A4ilY positive

self--;repo'rted fear,' o2entistry and -the measures of dental Anxiety. These, - )

c-hutionships were significant for the dent '- rating in Studies 1 and 3,-

the mother's rating in Study 3, and the M- ernal Questionnaire in Study 2.

Maternal anxiety again was inconsistently and mostly npusignificantly

related tb, the child's verbalized fear tistty. The only exception was*

the significant correlation of this measure with mothers' self rating of4. .

situational anxietys in Study 3.

The results

self-report measu

Discussion

sdlosed only a modest relationship between behavioral and

dental anxiety with the various predictor variables.

In general, dental anxiety and disruptiveness were negatively related to the

child's,-age as well as his state, trait, and dental anxiety. 'however, many of

these c relation§ were not significant. In fact, even the combined use of

several predictors of uncooperativeness by multiple regression procedures

was not helpful, as the specific variables and weights of the regresdion

equatians not repliented across samples. ,Therefore, these analyses were

not reported. These 'findings suggest that the child's anxity,toward dental

treatment is complexly determined, so that future

include multiple measures.

-earch.should continueto

9,10,study and Melamed et al- , theregwere ineon-'In eCordance.with our previous.

siatent,and nonsignificant relationships between the experienced patient's dentalI

Mate, 'rait,5or dental. We previously stiggeSted that such relationships

might be.-Confined to the first treatment session,-during -which the mother's and

patient's state anxiety might reach its peak. However, this association

laxgely absent among the inexperienced patients in Study 3 and children studied

10in their initial visit,4o_the dentist by Melamed et al. It is not clear why

these recent reports contradict 4arlier.findings relating maternal trait anxiety

6.and the pedodontic patient's uncooperativepess in treatment1-

. Perhaps uniden-

tified sample _ifferehces are invoW:ed, but this is unlikely in view of the simile

findings b red et al in Cleveland-and ourselvesin Rochester. The feet that

two thirds of the subjects in Studies. and , ere exposed to modeling procedures

is also not relevant, because the corAlations obtained among patients without

such an experience,. we were very similar.

Conclusion

1'

Clearly,,there is a need for-reevaluating the-popular belief that the child's

dental anxiety is acquired through imitation of his mother's attitudes o

direct maternal reinforcement of such fears. This theoretical position is

18grounded on what Chess,- has termed mal de m re, th 0 tendency to blame th6 mother

for -fast of the child's pSychological disorder, It may well be that parental'

T6-a-i. Of dentistry played a role in the phobie levels of fear of den stry uncovered

in sonfe Audies1221 but parental influence appears much less important !for

the moderatedisruptiveness at anxiety observed in the unselected samples studied

in the p esent research. Among such patients, fear of dentistry is more likely

22determined by unspecified situational factors -and like most rither,fear23

childhood , tends to decrease with age.

of

References

Johnson an Baldwin, D.C.: Relationship Materna_ Anxiety .toBehavior of Yoking Children Undergoing Dental xtraction, J pent Res47: 801-805, 1968.

Johnson R. and Mathen, J.R.; Behavior Modification Techniques andMaternal Anxiety, Dent Child 40: 272-276, 1973.

Johnson, R. and Baldwin, D.C.: Maternal Anxiety and Child Behavior,,J Dent Child .36:- 8.7-92,'1969.

Koenigsberg; S.R. and Johnson, R.J. i Child BehavierMuring SequentialDental Visits, J Amer'Dent Assoc_ 85: 128-132c-1972.'

5. Wri ht, G.Z. end Alpern, 0.D.; Vdriahles Influencing Children'sCooperative Be4vior,st the First Dental Visit, bent child' 38: 124 -128, -1971.

Wright, G.Z.; Alpern, G.D.;.and Leaks, The Modifiability ofernal,Anxiety as it Relates to Children's Cooperative Dental.

Behavior, J Dent child 40: 265-271; 1973.

Taylor, J.A.: A Personality Scale of Manifest Anxiety_, J Abnorm Socpsyehol 48,: 285-290, 1953.

Bailey, P.M. Talbot, A,; and:Taylor:p A Comparison of Maternal:Anxiety LeVels with Anxiety-Levels(,Manifested in the Child DentalVatiant,=J Dent Child 40: 277-284, 1973.

9. Klornam; R.; Ratner, J.; Arata, C.L.C.; King, J.B.; an Sveen, 0.8.:Predicting the Child's Uricooperativeness in Dental- Treatment from .

Maternal Trait, State, and Dental Anxiety, J Dent Child 45: 62-67, 1978.

10. Melamed, B.C.; Yarcheson, R.; Fleece, L.; Hutcherson, S1;.and Hawes,-R.:Effects of Film Modeling on the Reduction of ,Anxiety-related Behaviorsin Individuals-Varying id Level of Previous 'Experience in the Stress

. 1Situation, J ansitat Clin PsyCho4 in press.

11. Melamed, B.C.; Wein.stein, D.; Hawes, R.; and Katin-Borland, M.: Reduction,of Fear-Related Dental Management Probr'ems with Use of Filmed Modeling,J Amer Dent Assoc 90: 822-826, 1975.

12. Venham, L; Bengston, D.; and Cipes, .7 Children's Response to SequentialDental Visits, J Dent Res 56:' 454-459 1977.

13. Spielberger, C.D.; Edward, C.D.; Tushene, R.; Montouri, J., acid Platzck, D.:Manual for the State= alt Inventory for Children; the How I Feeluesti, Palo Alto: Consulting psychologists Press, 1970.

15.

Klerrian, R.; Hilpert, P.; Michael,-R; atl, C.L.0.; and Sveen, 0.B.:Effects of Coping and Mastery Modeling -on Experienced and inexperiencedPedodontic atients' DiPruptillgnesp submitted for publication._

Franki, S. Shiere, F. R.; an4 Fogels, -H. Should the 4',arena Remainwith the Child in the Dental OperatOry?, J Dent Ch-ild 29: 150063., 1962.

16. Bpielberger, C.D.; Gorsuch, R._ .; and Lushine, Manual.. for_ the

-xiet- inven Palo Alto: Consulting PsychologistsState-TraitPress, 1970.

17. Corate -, Development of a DentaI.Anxiety Scale, J Dent, Res 48:

596, 1969:

18. Chess, R.;: Mal de Mere, Am J CiLopstyALiaszi 341613, 1964..

Lautchi H.: Dental Phobia, Brit J Psychiat ,119; 151-158, 1971.:

20. Shoben, E.G. and Borland, L,: An Empirical Study of the Etiology _

Dental Fears, J Olin Psycbol 10: 171-174, 1954.

21. Shaw, 6_ DentallAnxiety in Children, Brit Dent J_ 139: 134-139,4975..

22. Misdhel, W. Personal and Asse sment, New York: Wiley, 1968,

23. Miller, L.C.; Sarret.t, C-.1.4 and Ha

Prescientific Era. In Devids; A.New-York:'Wiley 1974, p

E. Phobias of Childhood in aChild Personality and Psyios

9-134.

Table 1

een Rated Cooperatiyeness-and Predictors

Variable Study I :Study 2 Study 3

Age .126' -.279- .273

State Maternal Ratinga

.107 .137Anxiety

Picture Test .-.134 -.149 ,

How i Feelb -.4180xx - 053 -.084

Child Trait Anxietyb

DentalAnkietY

Maternal Questionnairea

Self reportF

Maternal Rating

Dentist's Rating

.345x

-.2

-.293

.726xx

.385

.432xx

-.355x

-.213

66

.011

416xx -.352x

State Ratinga

.224 ,.209 .-.424XxAnxiety

Self Evaluationd

-.065 ,240 -.157

Mather raft Anxiety

DentalAnxiety

Corah

.lamed

-.006. .241 -.210

.092 -491

.088 -.202 -.176

aAhigh score on this scale represents low anxiety. The ratings of'- ate anxiety

were made by the patient's mother on the Maternal Questionnaire.

Ffom Spielberger et al's How-I-Feel Quest onnaii7e.

cFrom Melamed et al's scale of dental anxiety.

d_Fr Spielberger et al's Self Evaluation Questionnaire

j

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.01

Corr -rib

, Table 2

een the Behavior Profile Scale and Predictors'

Variable Study 1 Study 2 Study 3

Age _.329XX-.410xx- -.008

State. Maternal -RatInga -.048 -.162 .067Anxiety

Picture Test -.057 .155

How I Feelb .202 .112

Child Trait Anxietyb

Dental'Anxiety

Maternal Questionnairea

Self Report°

Maternal Rating. -

Dentist's Rating

State Rating. Anxiety

Self Evaluation

Mother = Trait Anxiety

DentalAnxiety

orah

Melamed

.162 .111 '.045

-.238 -.092 .113

.347xx.123' .018

.101 320 -.071

.126 .227 - -.039

-.152 ':014 .104

-.058 .079 -.344

-.018 .150 -- -.043

-.116 :130x' -.272

-.091 .29J. -.112

aA high score on this scale represents low anxiety-. The, ratings of state anxie

were made by the patient's molhenon the Maternal Questionnaire:

b_From Spielbe gec et al' 1L-I-Feel Questionnaire.

cFrom Melamed et al's scale of dental anxiety.

d_7From Spielberger et al's Self Evaluation Questionnaire.

Table 3'

d irrela.t on and Predictors

Variable.

Age

Study 1

StateAniey

-rnal Ratii

Picture Test

llow 1 Feel

Child Trait Anxietyb

DentalAnxiety ,

aMaternal Questionnaire

MAernal Rating

Dentist's Rating

Study g Study

303 -t173

.217. -3244 -.226

.0.12

. 81x

.155 .191

-.167

.306x .263

.220 -96'

.450x

.329x

.384xx .290

.268.386

-.301

.337

\415x

State

Aiikiety

Ratine

Self-Eva1U-'

-.082 .020_.405x

157 .131. -.072

Mother Trait Anklet .103 -.052

-DentaAnxiety

R,p rah

Melamed

-.054 .101' .178

-.082 .020 041

aA high score on ;;cafe represents low ratings f state -nklety.

were made by the patient's mother on the Maternal estionnaire.

6,From Spielberger et al's 1! -I-Feel Qu'estionnaire

om `Spielberger et al's SctlSc Evaluation Questionnaire.

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.01