Mothers Attitude and How It Influences Their Children s Behaviour During Their First Dental Visits

ORIGINAL PAPERS Dent. Med. Probl. 2007, 44, 1, 74 79 ISSN 1644 387X Copyright by Silesian Piasts University of Medicine in Wrocław and Polish Stomatological Association BEATA WILK SIECZAK, URSZULA KACZMAREK Mothers Attitude and How It Influences Their Children s Behaviour During Their First Dental Visits Postawa matki i jej wpływ na zachowanie dziecka podczas pierwszej wizyty dentystycznej Department of Conservative Dentistry and Pedodontics, Silesian Piasts University of Medicine in Wrocław, Poland Abstract Background. Many additional skills are required from the dentist to treat children. One of them is careful obser vation of the mother and her child in the dental environment as well as the accurate evaluation of her emotional attitude and how it affects her child s behaviour. The mother s presence in the dental surgery during her child s treatment, which in particular refers to little children, is necessary to establish and maintain appropriate rela tions between the dentist and his/her patient. In addition, the changes taking place in our society enforce the par ent s presence in the dental surgery in the course of treatment. Appropriate assessment of mutual relations between the mother and her child enables the dentist to predict the child s reactions to a scheduled dental treatment and makes it possible to employ the most efficient techniques of individual behaviour management. Objectives. The aim of this study was to assess mothers attitude during their children s first dental visits. Material and Methods. In the study, 33 mothers and their children were involved. The little patients were seen in an especially prepared surgery by the same dentist using a standard tell show do adaptation method. The visits were videoed and analysed by three independent experts (psychologists). The mothers and their children s atti tudes were evaluated according to the criteria developed by the author. The results were statistically analysed and Pearson s correlations were calculated. Results. The mothers and their children s average ages were 27.1 ± 6.6 years and 23.6 ± 6.8 months respective ly. During their first dental visits, most mothers and their children were sitting in the dental chair together. In more than a half of cases (57.6%), mothers manifested the cooperative attitude. Only 3% displayed the neutral one, whereas the rest of them showed the passive and impeding attitude. In the majority of the children, the precooper ative attitude was observed. Conclusions. The mothers neutral attitude was significantly interrelated with the children s co operative attitude (Dent. Med. Probl. 2007, 44, 1, 74 79). Key words: mother s attitude, child s attitude, first dental visit. Streszczenie Wprowadzenie. Leczenie dentystyczne dzieci wymaga od lekarza posiadania wielu dodatkowych umiejętności. Jedną z nich jest uważna obserwacja matki i dziecka w środowisku dentystycznym, a także ocena postawy emo cjonalnej matki i jej wpływu na zachowanie dziecka. Obecność matki w gabinecie podczas leczenia dziecka, zwła szcza małego, jest konieczna do ustalenia i prawidłowego utrzymywania relacji między lekarzem dentystą a pa cjentem dzieckiem. Ponadto zmiany zachodzące w społeczeństwie wymuszają obecność rodzica w gabinecie dentystycznym podczas leczenia dziecka. Poprawnie przeprowadzona ocena wzajemnej relacji między matką a dzieckiem pozwala przewidywać jego reakcje na planowane postępowanie terapeutyczne oraz umożliwia zasto sowanie najbardziej skutecznych metod indywidualnego kształtowania zachowania. Cel pracy. Ocena postawy matek podczas pierwszej wizyty dziecka. Materiał i metody. Badaniem objęto 33 matki i ich dzieci. Pacjentów przyjmował ten sam lekarz, posługując się standardową metodą adaptacji tell, show, do w odpowiednio do tego celu przeznaczonym gabinecie. Wizyty te na grano na kasety wideo i poddano ocenie przez trzech niezależnych sędziów kompetentnych (psychologów). Oce niono postawy matek i dzieci według własnych kryteriów. Otrzymane wyniki poddano analizie statystycznej i obli czono korelację liniową Pearsona.

Mother s Influence on Their Children First Dental Visit 75 Wyniki. Średni wiek badanych matek wynosił 27,1 ± 6,6 lat, a dzieci 23,6 ± 6,8 miesięcy. Podczas pierwszej wi zyty większość matek (84,8%) siedziała razem z dzieckiem na fotelu dentystycznym. W ponad połowie przypad ków (57,6%) matki manifestowały postawę współpracującą. Jedynie 3% wykazała postawę neutralną. Pozostałe charakteryzowały się postawą bierną (27,3%) i utrudniającą (12,1%). U dzieci zaobserwowano w większości po stawę przedwspółpracującą (69,7%). Wnioski. Postawa neutralna matki była istotnie współzmienna z postawą współpracującą dzieci (Dent. Med. Probl. 2007, 44, 1, 74 79). Słowa kluczowe: postawa matki, postawa dziecka, pierwsza wizyta. Positive attitude to dental treatment should be built by the mother and the dentist during several introductory dental visits [1, 2]. Such behaviour management should start before caries lesions appear and not later than within eighteenth months of live. Invasive procedures are not recommended in the case of developing patients. Modification of the child s behaviour through appropriate adapta tion action is a significant stage preceding the main treatment. Behavioural methods of dealing with children patients in the dental surgery are defined by the American Academy of Pediatric Dentistry (AAPD) as a continuum of interaction with a child/parent directed toward communication and education [3]. This continuum starts from nonver bal and verbal techniques which constitute the basis for communication with both co operative and non cooperative patients. The mother s pres ence in the surgery in the course of her child (espe cially a little one) treatment is necessary for estab lishing and proper functioning of the dentist child patient relations. Moreover, the changes taking part in our society put pressure on the dentist to accept such parental presence. Thus, getting to know the mother as well as evaluation of her attitude during her child s dental visit are essential for building up the dentist child patient relationships. Material and Methods In the study, 33 mothers and their children were involved. The average mothers age was 27.1 ± 6.6 years and the average age of their chil dren was 23.6 ± 6.8 months. The children were examined by the dentist for the first time in their lives. A traditional tell show do method by Addelston, recommended by the American Acad emy of Pediatric Dentistry, was used in the course of these visits [3 7]. It consists in explaining a planned procedure to the child, and then demon stration followed by its performance. All the den tal appointments were videoed and judged by three independent experts (psychologists). Then, their evaluations were verified with the chi square and Kendall tests. The consistency of the experts judgements was about 99%. Further statistical analysis was carried out with the averaged data obtained from the experts. The criteria developed by the author were used to assess the mothers attitude during the first visit. Seven distinguished stages were evaluated during the visits: 1) entering the surgery, 2) activities in the dental chair, 3. conversation with the child, 4) showing, 5) carrying out a procedure, 6) reward ing, 7) leaving the surgery. The numbers of neu tral, co operative and impeding behaviours mani fested by the mothers were analysed during the particular stages of their children s visits. They were scored as follows: neutral stage (NS) 1 point, co operative stage (CS) 0 points, imped ing stage (IS) ( ) 1 point. The total score, obtained from all the stages of a given dental appointment and ranging from 7 to 7 points, allowed to categorize the mothers atti tudes in the course of their children s visits in the dental surgery as neutral (from 7 to 4 points), co operative (from 3 to 0 points), passive (from 1 to 3 points) and impeding (from 4 to 7 points) (see Table 1). The evaluation of the children s behaviour in the particular stages of their visits was conducted in a similar way, and the following types of their behaviour were distinguished: co operative, pre cooperative and impeding (see Table 2). It enabled to assess each stage of the visit and to ascribe numerical values: co operative stage (CS) 1 point, precooperative stage (PS) 0 points, imped ing stage (IS) ( )1 point. The total number of points obtained from all 7 stages served as the basis for classifying the children s behaviour along the interval scale ranging from 7 to 7, and the following attitudes were distinguished: cooper ative (from 7 to 4 points), precooperative (from 3 to 0 points), precooperative with impediments (from 1 to 3 points) and impeding (from 4 to 7 points). The purpose of this study was to assess the mothers attitudes displayed in the course of their children s first dental visits and explain how such attitudes are related to the attitudes manifested by the children.

76 Results and Discussion In the course of their first dental appointment, most children (84.8%) were sitting on their moth ers laps (see Table 3). The percentage of the chil dren sitting in the dental chair on their own (15.2%) during their first visit turned out to be sig nificantly lower compared with the 3 year olders from Sweden 69.0% [8]. The child s behaviour depends both on the maturity of their personality as well as on environmental factors. It is also influ B. WILK SIECZAK, U. KACZMAREK enced by children s various positive and negative experiences. Children from the families character ized by their high sense of safety, who feel that they are loved and who confide in adults much faster settle into new environment compared with the ones who are uncertain of their closest peo ple s feelings, immature, apprehensive and afraid of being left alone [9]. Such children particularly need their parents support and individually adjusted adaptation procedures. Therefore, being able to sit by oneself in the dental chair is the hall Table 1. Types of the mother s behaviours observed during particular stages of her child s visit Tabela 1. Rodzaje obserwowanych zachowań matki podczas fazy wizyty Types of behaviour (Rodzaj zachowań) Neutral (Neutralne) NS = 1 point Co operative (Współpracujące) CS = 0 points Impeding (Utrudniające) IS = 1 point Characteristics of behaviours (Charakterystyka zachowań) the mother s verbal and nonverbal actions make it possible for the dentist to communicate directly with her child, the mother withdraws from dentist child mother triad, allows the dentist to contact her child, she does not mediate the dentist child communication, the child cooperates and copes without his/her mother s help, the mother stays in the surgery or, in the case of older children, waits in the corridor the mother supports the dentist s activity through her verbal and nonverbal (words, gestures, touch, embrace, cuddle) behaviour, which decreases the child s resistance and increases his/her co operation the mother impedes the dentist s actions through her verbal and nonverbal influence (words, gestures, accidental responses, interrupting the dentist in mid sentence, demanding too much from her child, the symptoms of her own dental anxiety expressed verbally and through ges tures, which makes her child more resistant to the dentist actions and decreases co operation) Table 2. The types of observed behaviours in up to 3 year old children during their dental visits (in the course of 7 stages of the visit) Tabela 2. Charakterystyka obserwowanych zachowań dziecka podczas danej fazy Type of child s Turning point Characteristics of child s behaviour in dentist child mother/carer behaviour in starting co operation triad interaction during particular visit stage particular stage with child (Charakterystyka zachowania dziecka w triadzie (Rodzaj zachowań (Punkt zwrotny stomatolog dziecko matka/opiekun w danej fazie wizyty) dziecka w danej rozpoczęcie współpracy fazie wizyty) z dzieckiem) Co operative appears very clearly good interaction with the dentist (verbal and nonverbal), the child is (Współpracujące) CS = 1 point interested in the dentist s activity, complies with the dentist s orders, participates in demonstrating new things, smiles and displays symp toms of consent (gestures, words) to perform a procedure Pre cooperative appears interchangeably varied interactions with the dentist (verbal and nonverbal), the child (Przedwspółpracujące) with impeding behaviour listens to the dentist and usually does not answer questions but PS = 0 points always appears a turning point, symptoms of anxiety and fear of unknown which impede cooperation are visible (crying, distancing from the dentist, withdrawing from participation in demonstrating new things). Regression of behaviour (sudden crying, moving back). Such children are characterized by decrease in intensity of such behaviours in a given stage till they become completely calm Impeding co operation there is no clear turning varied (verbal, nonverbal) contact with the dentist, the child does not (Utrudniające point listen to the dentist and usually does not answer questions, there is współpracę) no clear turning point, the symptoms of anxiety and fear of unknown IS = 1 point which impede cooperation are visible (crying, distancing from the dentist, withdrawing from participation in demonstrating new things). Regression of behaviour. They are characterized by the increase in such behaviours during a given stage to display extreme ly negative ones e.g. hysteria, shouts, escaping from surgery, cover ing face, kicking, breaking free from the mother/carer)

Mother s Influence on Their Children First Dental Visit 77 Table 3. Sitting down on the dental chair Tabela 3. Zajmowanie miejsca na fotelu dentystycznym The ways of sitting down n/n % on the dental chair (Zajmowanie miejsca na fotelu dentystycznym) On one s own (Samodzielnie) 5/33 15,2 On mother s lap (Na kolanach u matki) 28/33 84,8 Total (Razem) 33 100,0 Table 5. The mothers attitude during their children s first dental visits Tabela 5. Postawa matek podczas pierwszej wizyty dziecka Mother s attitude n/n % (Postawa matek) Neutral (Neutralne) 1/33 3.0 Cooperative (Współpracujące) 19/33 57.6 Passive (Bierne) 9/33 27.3 Impeding (Utrudniające) 4/33 12.1 Total (Razem) 33 100.0 Table 4. The mother s behaviour during seven stages of her child s first visit Tabela 4. Zachowanie matki podczas siedmiu faz pierwszej wizyty Stage of visit NS CS IS (Faza wizyty) n/n % n/n % n/n % 1. Entering 0/33 0.0 32/33 97.0 1/33 3.0 (Wejście) 2. Taking seat on dental chair 3/33 9.1 26/33 78.8 4/33 12.1 (Zajęcie miejsca na fotelu dentystycznym) 3. Conversation 4/33 12.1 24/33 72.7 5/33 15.2 (Rozmowa) 4. Showing 3/33 9.1 21/33 63.6 9/33 27.3 (Pokazywanie) 5. Performance 3/33 9.1 22/33 66.7 8/33 24.2 (Wykonywanie) 6. Rewarding 6/33 18.2 24/33 72.7 3/33 9.1 (Nagradzanie) 7. Leaving surgery 0/33 0.0 33/33 100.0 0/33 0.0 (Wyjście) NS neutral stage (prevalence of neutral behaviours). CS cooperative stage (prevalence of cooperative behaviours). IS impeding stage (prevalence of impeding behaviours). NS neutralne (występowanie zachowań neutralnych). CS współpracujące (występowanie zachowań współpracujących). IS impeding stage (występowanie zachowań utrudniających). mark of maturity and can be a predicator of good child s co operation irrespective of environmental factors. The mothers behaviour during 7 phases of the first visit was evaluated as neutral, co operative or impeding. In the mothers participating in the research, cooperative attitude prevailed ranging in all the stages of their visits from 63.6% to 97.0%. Neutral behaviour was observed most often in the sixth i.e. rewarding phase 18.2%, whereas im peding one was found more frequently in stage 4 (showing) 27.3% (see Table 4). The prevalence of cooperative behaviours probably resulted from the willingness to help the child to cope with a dif ficult dental situation. The literature indicates various dentists approach to a parent s (usually mother) presence during therapeutic procedures administered to her child, the problem frequently discussed in profes sional journals. Opponents say that the moth er s presence is used by her child to carry out his/her own goals like refusing treatment, whereas adherents believe that separating the child from their mother results in the decrease of anxiety and disorders the application of treatment procedures [10, 11]. The reasons for such discussions are like ly to be associated with the nature of the dentist mother child triangular interaction, where the den tist s therapeutic activity is aimed at two people a patient and his/her carer. The mother s absence makes this relation a bilateral one as it is the case with adult patients. Most often mothers were characterized by cooperative (57.6%) attitude, then by passive (27.3%), and impeding (12.1%) one. Neutral atti tude, which allows to directly start a relationship

78 B. WILK SIECZAK, U. KACZMAREK Table 6. The children s attitudes during their first dental visits Tabela 6. Postawy dzieci podczas wizyty Children s attitudes n/n % (Postawa dzieci) Neutral (Neutralne) 6/33 18.2 Cooperative (Współpracujące) 23/33 69.7 Passive (Bierne) 3/33 9.1 Impeding (Utrudniające) 1/33 3.0 Total (Razem) 33 100.0 with the child was only found in 3.0% of the moth ers (see Table 5). During their first dental, visits the children most often revealed precooperative attitude (69.7%), then cooperative (18.2%) and precooper ative with impediments (15.2%). Impeding atti tude, described in the literature as noncooperative or definitely negative, was only manifested by 3.0% of the participants (see Table 6). These results are, to some extent, different from the ones pub lished earlier concerning older children. Holst and Crossner found the acceptance of therapeutic pro cedures in 79.0% of 3 16 year old children [12]. In another work, Holst et al. revealed good coopera tion during the examination of the oral cavity in 76.0% of their 3 year old patients attending their first dental appointments [8]. Unwilling and nega tive attitudes were only manifested by 13.0% and 11.0% respectively. Hawley et al., however, observed that over a half of the behaviour problems of their 26 84 months old patients were shown by the up to 3 years old children [13]. The cooperation of as many as 75.0% of them was evaluated in a decisively negative way. However, such a large number of negatively evaluated little children might have resulted from the Frankl s scale employed to measure their behaviour, which is an accurate and effective tool for older children char acterized by well formed verbal communication. It should not be used to evaluate up to 3 year olds as most of their correct behaviours in new surround ings (and not only dental one) is negatively evalu ated by this scale. As it has been shown by own our studies, precooperative attitude revealed by the up to three year old children during their first dental visit is a common one [14]. Many papers have dealt with the analysis of the factors influencing the child s attitude to treatment and the ways of its management but very few of them have concerned three year olders and hardly any of them have referred to younger children [8]. As it was revealed by Rud and Kisling, the child who has achieved mental development assumed for the age of 29 months is capable of cooperating in the dental environment [15]. If, however, mental development does not follow physical one a child may not accept examination of his/her oral cavity. Taking into account the above data, our research involved the children aged on average 23.6 ± 6.8 months (the age range from 8 to 35 months). Appearance of the child s fear and anxiety, child parent interactions as well as the cause effect relation between the mother s attitude and her child s behaviour in the dental surgery are empha sized in the course of the first dental visit [16 18]. In our study, a significant (p < 0.05) effect of the mothers attitude on their children s behaviour dur ing their first visits was found (see Table 7). What is more, it was also revealed that the mothers neu tral attitude was positively correlated with and their children s cooperation during their first dental appointment (p < 0.05; r = 0.38). The child s first dental visit is a key moment in his/her adaptation to dental treatment, and it is also an appropriate source of individually adjusted infor mation on the state of a given patient s oral cavity [19]. It is generally agreed that such a visit substan tially influences children s attitudes to treatment Table 7. The effect of the mothers attitude on their children s behaviour during their first dental visit Tabela 7. Wpływ postawy matki na postawę dziecka podczas pierwszej wizyty Mother s attitude Child s attitude Significance level Pearson s correlation (r) (Postawa matki) (Postawa dziecka) (Poziom istotności) (p) (Współczynnik korelacji Pearsona) Mother s neutral attitude child s co operative attitude * 0.38 (Neutralna) Mother s passive attitude child s co operative attitude t 0.24 (Bierna) Mother s co operative attitude child s preco operative attitude t 0.23 (Współpracująca) t 0.1 > p > 0.05; *p < 0,05 r Pearson s correlation coefficient t 0,1 > p > 0,05; *p < 0.05 r współczynnik korelacji Pearsona.

Mother s Influence on Their Children First Dental Visit 79 and their confidence in the dentist [20 23]. The first step to obtain good relationships with the children is to prepare their mothers for the cooperation within the dental triad. If such relationships develop in a positive way, they have an important effect both on consolidating the mother s cooperative attitude, and then shaping her neutral attitude, which in turn facilitates her child s cooperation. References [1] DELIATALA G.: Incorporating Piaget s theories into behavior management techniques for the child dental patient. Gen. Dent. 2000, 48, 74 76. [2] WILK SIECZAK B., CHMIELEWSKA ŁUCZAK D.: Adaptacja do leczenia stomatologicznego dzieci do lat 2 (doniesie nie wstępne). Materiały: Międzynarodowa Konferencja Naukowa Problemy w Ochronie Zdrowia XXI wieku, Poznań 2002, 61. [3] ADAIR S.M., WALLER J.L., SCHAFER T.E., ROCKMAN R.A.: A survey of members of the American Academy of Pediatric Dentistry on their use of behavior management techniques. Pediatr. Dent. 2004, 26, 159 166. [4] ADDELSTON H.K.: Child patient training. Fort. Rev. Chicago Dent. Soc. 1959, 38, 27 29. [5] WRIGHT G.Z., STARKEY P.E., GARDNEM D.E., CURZON M.E.J: Child Management In Dentistry. Published under the Wright G.Z., IOP Publishing Limited. Bristol 1987. [6] KOCH G., MODEER T., POULSEN S., RASMUSSEN P.: The child as a dental patient. Pedodontics a clinical approach. Munksgaard, Copenhagen 1994, 64 77. [7] American Academy of Pediatric Dentistry. Clinical guideline on behavior management. Reference Manual, 2003/2004, 25, 7, 69 74. [8] HOLST A., HALLONSTEN A.L., SCHRODER U., EK L., EDLUND K.: Prediction of behavior management problems in 3 year old children. Scand. J. Dent. Res., 1993, 101, 110 114. [9] BRZEZIŃSKA A.: Adaptacja dziecka do przedszkola rola nauczycielki w uczeniu się pokonywania trudności przez dziecko. Adaptacja dziecka do przedszkola i szkoły. Oddział Doskonalenia Nauczycieli. Szczecin 1990, 7 72. [10] GUTHRIE A.: Separation anxiety; an overview. Pediatr. Dent. 1997, 19, 486 490. [11] FREEMAN R.: The case for mother in the surgery. Br. Dent. J. 1999, 186, 610 613. [12] HOLST A., CROSSNER C. G.: Direct ratings of acceptance of dental treatment in Swedish children. Commun. Dent. Oral Epidemiol. 1987, 15, 258 263. [13] HAWLEY B., MCCORKLE A., WITTEMANN J., OSTENBERG P.: The first dental visit for children from low socioeco nomic families. J Dent. Child. 1974, 41, 376 381. [14] WILK SIECZAK B., GMYREK MARCINIAK A.: Zachowania dzieci podczas wizyty adaptacyjnej a stosunek rodziny do leczenia stomatologicznego. Dent. Med. Probl. 2005, 42, 573 580. [15] RUD B., KISLING E.: The influence of mental development on children s acceptance of dental treatment. Scand. J. Dent. Res. 1973, 81, 343 352. [16] AL SHALAN T.A.: Factors affecting Saudi parent s perception of their children s first dental visit. J. Contemp. Dent. Pract. 2003, 4, 54 66. [17] HARPER D.C., D ALESSANDRO D.: The child s voice: understanding the contexts of children and families today. Pediatr. Dent. 2004, 26, 114 120. [18] DO C.: Applying the social learning theory to children with dental anxiety. J. Contemp. Dent. Prac. 2004, 5, 126 135. [19] GRZESIAK I., KACZMAREK U.: Pierwsza wizyta dziecka w gabinecie stomatologicznym. Dent. Med. Probl. 2006, 43, 433 437. [20] WRIGHT G.Z., ALPERN G.D.: Variables influencing children s cooperative behavior at the first dental visit. J. Dent. Child. 1971, 38, 124 8. [21] WRIGHT G.Z., ALPERN G.D., LEAKE J.L: The modifiability of maternal anxiety as it relates to children s coopera tive dental behavior. J. Dent. Child 1973, 40, 265 271. [22] WRIGHT G., ALPERM G., LEAKE J.: A cross validation of variables affecting children s cooperative behaviour. J. Can. Dent. Assoc. 1973, 39, 268 73. [23] TOWNEND E., DIMIGEN G., FUNG D.A.: A clinical study of child anxiety. Behav. Res. Ther. 2000, 38, 1, 31 46. Address for correspondence: Beata Wilk Sieczak Department of Conservative Dentistry and Pedodontics Silesian Piasts University of Medicine Krakowska 26 50 425 Wrocław Poland Tel. +48 71 784 03 61, fax +48 71 784 03 62 E mail: beataws@ak.am.wroc.pl Received: 25.01.2007 Revised: 12.02.2007 Accepted: 12.02.2007 Praca wpłynęła do Redakcji: 25.01.2007 r. Po recenzji: 12.02.2007 r. Zaakceptowano do druku: 12.02.2007 r.