Personality Factors Affecting the Preschool Child's Response to Dental Stress L. L. VENHAM, P. MURRAY, and E. GAULIN-KREMER University of Connecticut Health Center, Farmington, Connecticut 06032
role of basic personality factors such as trait anxiety, neuroticism, introversion, or dependency.4'5 Other workers have contended that dental fears are largely acquired, and represent responses conditioned by familial attitudes and/or a previous, unpleasant experience.6-8 Several retrospective studies of dentallyJ Dent Res 58(11):2046-2051, November 1979 anxious adults have been conducted, using interview and questionnaire approaches. 4,6,7,12 These studies identify traumatic Introduction. dental experience during childhood as one primary factor in the acquisition of negaThe recent pedodontic literature reflects tive dental attitudes. Reports of unfavora growing concern with the problem of able attitudes toward dentistry among childhood dental anxiety. Most young family members were also found more children experience some anxiety in their frequently in fearful than nonfearful adults. initial dental contacts, but wide individual Findings regarding the importance of paindifferences are apparent. The variability in ful experience and negative family attitudes children's dental anxiety has been well- support the usefulness of viewing dental described by Swallow.1 At one extreme fears as learned responses to the stimuli are those happy and relaxed children who intrinsic to the dental context. However, readily accept any form of dental treatment; these findings do not preclude the potential at the other are those extremely fearful chil- importance of personality traits in modudren who resist every form of treatment lating the learning process. For example, offered. Anxious children demand consider- Forgione and Clark,1 3 re-analyzing Shoben able dedication and expertise in child and Borland's6 data, reported that low pain management techniques from the dental tolerance and high trait anxiety were further staff. For effective management of the important contributors to odontophobia. young pedodontic patient, an understand- Lautch4 also noted that neurotic traits in ing of the etiology of children's stress re- childhood were an additional predisposing sponses is vitally needed. factor in the development of dental phobia. Existing theories of the origins of dental Longitudinal prospective studies of childanxiety are largely speculative, represent- hood dental anxiety have only recently ing untested extrapolations from the psy- begun to emerge.9-1 1 Initial results from choanalytic, personality, or behavioristic these projects suggest that dental anxiety literatures. Psychoanalytically-oriented work- is a dynamic phenomenon, which evolves ers have stressed the special significance in a complex and variable manner as dental of the oral zone.2,3 Some authors, noting experience accumulates. the large variability among children in Sermet5 and Shaw14 collaboratively anxiety manifestations, have emphasized the studied 100 dentally-anxious and 100
Responses to dental stress were evaluated in 26 preschool children during an initial examination visit. Measures of the children's developmental status and personality were collected during a home visit. Significant relationships emerged which suggest that personality development influences children's ability to tolerate dental stress.
Received for publication December 11, 1978. Accepted for publication January 18, 1979.
This research was partially supported by Grant No. lR23-DE03891-02 from the National Institute of Dental Research.
2046 Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
Vol. 58 No. II
PRESCHOOL PERSONA LITY AND DENTAL
STRESS
2047
dentally non-anxious children. Emotional who independently viewed videotapes of attributes and medical and dental histories the visits. A six-point rating scale (Table 1) of the children and their parents were was used to score each visit period. The assessed by parental interviews and question- judges' ratings for each period were avernaires. Dental anxiety emerged as a complex aged, and these period scores averaged to phenomenon which reflects multiple inter- yield a mean anxiety rating for each visit. acting variables. Significant differences be- Pre-training of the judges ensured intertween the two groups of children were rater reliabilities exceeding .80. Following the dental visit, a trained found in their introductions to dentistry, their dental experiences, and their mothers' researcher visited the child's home for a dental attitudes and experiences.14 Medical 90-minute period. Developmental, personand emotional factors also differentiate ality, and child-rearing data were collected; the two groups. Behavioral or emotional the child-rearing data are reported elsedisorders were found in 31% of the dental- where.5 ly-anxious children, but in only 6% of the TABLE 1 non-anxious children. A generally nervous RATING SCALE ANXIETY CLINICAL or high-strung disposition was described for 54% of the dentally-anxious children, but for none of the non-anxious subjects.5 The findings reviewed above strongly 0. Relaxed, smiling, willing and able to converse. During stressful procedure, implicate basic personality factors in the 1. Uneasy, concerned. may protest briefly and quietly to indicate etiology of dental anxiety. This study was discomfort. Hands remain down or partially undertaken to further clarify the relationraised to signal discomfort. Child willing and ship between developmental-personality able to interpret experience as requested. variables and the preschool child's response Tense facial expression, may have tears in to dental stress. eyes. 2. Child appears scared. Tone of voice, questions
Materials and methods.
The subjects were 26 children, aged three-to-five years, with no prior dental experience. The children were participants in a longitudinal project assessing children's responses to sequential dental visits. The study sample was established by including all three-to-five-year-olds who enrolled in the longitudinal project during a consecutive six-week period. All subjects had uneventful medical histories and were not receiving any medication. Each child's response to dental stress was assessed during his/her initial dental examination visit. This visit was divided into three periods corresponding to the mirror and explorer exam, prophylaxis, and topical fluoride application. Data collected included heart rate and clinical anxiety ratings. Heart rate was recorded using a photoelectric sensor clipped to the child's finger and was converted to beat-to-beat HR data via a biotachometer. HR was sampled for a 99-beat interval at the outset of each visit period. A mean HR value for the visit was obtained by averaging all beat-to-beat HR samples. Clinical anxiety ratings were made by three judges, naive to the study purposes,
and answers reflect anxiety. During stiessful procedure, verbal protest, (quiet) crying, hands tense and raised (not interfering much - may touch dentist's hand or instrument, but not pull at it). Child interprets situation with reasonable accuracy, and continues to work to cope with his/her anxiety. 3. Shows reluctance to enter situation, difficulty in correctly assessing situational threat. Pronounced verbal protest, crying. Using hands to try to stop procedure. Protest out of proportion to threat. Copes with situation with great reluctance. 4. Anxiety interferes with ability to assess situation. General crying not related to treatment. More prominent body movement. Child can be reached through verbal communication, and eventually, with reluctance and great effort, he/she begins the work of coping with the threat. 5. Child out of contact with the reality of the threat. General loud crying, unable to listen to verbal communication, makes no effort to cope with threat. Actively involved in escape behavior. Physical restraint required.
Developmental measures included the Denver Developmental Screening Test, the Peabody Vocabulary Test, and the Vineland Social Maturity Scale. The Denver Developmental Screening Test (DDST)16 is a standardized instrument for detecting children
Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
2048
J Dent Res November 1 9 79
VENHAMETAL.
with significant social, language, or motor delays. A series of developmental tasks and milestones are surveyed to classify the child's progress as either normal or delayed. The Peabody Picture Vocabulary Test (PPVT)17 is a reliable, easily-administered test of verbal intelligence. The test consists of a graduated series of plates, each containing four pictures; the subject points to the picture matching each spoken stimulus word. Raw PPVT scores are converted into mental ages, standard-score intelligence quotients, and percentile ranks. The Vineland Social Maturity Scale (VSMS)1 8 is a rapidly-administered checklist measuring the child's progress toward independence and social competence. Scoring is based on parental report. Raw scores can be converted into social ages and social quotients. Personality data were collected using the Preschool Personality Questionnaire and the Self-Concept and Motivation Inventory. The Preschool Personality Questionnaire (PSPQ)19,20 consists of a series of twochoice questions verbally administered to the preschool child. Sample questions include, "Would you rather (a) color a book, or (b) climb a tree?" and "Do you like to (a) keep your room neat and clean, or (b) mess it up?" Responses were analyzed to yield scores on 13 personality dimensions. The Self-Concept and Motivation Inventory (SCMI)21 is a 24-item pictorial rating scale available in a verbally-administered preschool version. Each question poses a hypothetical situation to which the child responds by selecting one of three faces. A sample question is, "What face would you wear if you had done something that would get you a spanking?" Pilot work indicated that children participated more eagerly when age-appropriate cartoon figures were substituted for the original stylized line drawings (Figure 1). Responses yield a Self-Concept factor, subdivided into SelfAdequacy and Role Expectation, and a Motivation factor, subdivided into Achievement Need and Failure Avoidance. Tasks administered to the child were presented as a game and conducted in a relaxed manner. To maintain the child's optimal cooperation, interviewing was periodically interrupted to provide an opportunity for a more physically-active task. Statistical analyses were performed to evaluate relationships between the dental
stress measures and the developmental and personality variables. Heart rate data were analyzed using the Pearson product-moment coefficient, a parametric correlational statistic. Clinical anxiety ratings were analyzed via a non-parametric statistic, the Spearman correlation coefficent.
Results. Developmental variables. - Developmental status assessed by the DDST was not significantly related either to heart rate or clinical anxiety. However, scores on the PPVT and VSMS were inversely related to the dental stress indices (Table 2). Percentile rank on the PPVT was negatively correlated with heart rate, whereas social age and social quotient on the VSMS were negatively correlated with both heart rate and clinical anxiety. TABLE2 CHILDREN'S DEVELOPMENTAL STATUS AND RESPONSES TO DENTAL STRESS
PPVT
Heart Rate Clinical Anxiety
Mental Age Intelligence Quotient Percentile Rank
-.29 -.23 -.39*
-.20 -.09 -.18
-.39* -.47**
.44* -.44*
VSMS
Social Age Social Quotient *p < .05 **p < .01
TABLE3
CORRELATIONS BETWEEN SCMI SCORES AND CHILDREN'S RESPONSES TO DENTAL STRESS
Heart Rate
Self-adequacy Role Expectation Self-Concept Achievement Need Failure Avoidance Motivation *
-.63*** -.67*** -.67*** .29 .46* .44 *
Clinical Anxiety -.80*** -.77*** -.85*** .44* .73*** .64***
p < .05
**p < .01 *
p < .001
Personality variables. - Relationships between the SCMI factors and the dental
Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
Vol. 58 No. 11
PRESCHOOL PERSONALITY AND DENTAL STRESS
stress measures are presented in Table 3. Lower scores on the Self-Adequacy, Role Expectation, and Self-Concept factors were associated with higher heart rates and anxiety ratings. Higher scores on Achievement Need, Failure Avoidance, and Motivation were associated with more anxious dental responses. Personality factors tapped by the PSPQ also bore strong relationships to the children's responses under dental stress (Table 4). Personality traits associated with higher heart rates and/or clinical anxiety scores included: guilt, insecurity, dissatisfaction, aggressiveness, fearfulness, anxious rebelliousness, anxious depressiveness, passive withdrawal, cautious immaturity, misanthropic pessimism, self-distrust, and self-rejecting
submissiveness.
Discussion. The results of this investigation confirm the role of basic developmental and personality factors in the etiology of childhood dental anxiety. In the absence of previous dental experience, the subjects showed
a wide spectrum of responses to the dental visit. Furthermore, the nature of the child's response to dental stress was strongly related to basic dimensions of personality development. Children who were relatively delayed in social and language development tended to exhibit a more anxious response to the dental visit. Perhaps these children were unable to fully comprehend and realistically appraise the nature of dental treatment, or to understand explanations and instructions. Such deficits in realistically appraising the stresses inherent to the dental context may have predisposed these children to magnify the degree of threat and, consequently, to experience greater anxiety. It is also plausible that the developmentallyslower children had fewer skills and resources available for coping with the actual stresses of dental procedures. Certain personality traits also seemed to predispose children to respond anxiously on their first exposure to the dental situation. The present results are compatible with, and extend previously-cited, findings,
What Face Would You Wear? Sample
2049
/P
£L
ORIGINAL STIMULI FOR THE SCMI
CARTOON FIGURES USED AS SCMI STIMULI IN THE PRESENT STUDY
Fig. 1 -Original and revised stimuli for the Self-Concept and Motivation Inventory
(SCMI).
Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
2050
VENHAM ETAL.
suggesting that ability to tolerate dental stress is at least partially mediated by personality factors, such as trait anxiety and introversion. Greater dental anxiety was associated with SCMI and PSPQ scores indicative of lower self-adequacy and selfconcept, and higher guilt, self-distrust, and self-rejection. These results suggest that children with lower self-esteem respond less favorably to dental stress. More anxious dental responses were also shown by children with scores indicative of insecure, fearful, anxious-rebellious, or anxiousdepressive personality dispositions. Such findings suggest that, as might be expected, children who are generally more anxious tend to exhibit greater situational stress. Finally, higher heart rates and/or anxiety ratings were correlated with personality dispositions of passive withdrawal, cautiousness, pessimism, and avoidance of failure. Thus, it appears that children who are less willing to act and take risks experience greater dental anxiety.
J Dent Res November 1 9 79
Conclusions. Our investigation strongly supports the notion that the young patient brings to the initial dental experience internal characteristics which may either facilitate or impede his/her adaptation to this stress. Certain developmental and personality characteristics may predispose the young dental patient to perceptually distort the degree of threat present, and to unrealistically interpret the amount of discomfort actually experienced. Our findings, therefore, do not support the belief that dental anxiety is solely or primarily a conditioned response to past traumatic dental experiences. Rather, we believe that the literature, to date, can be organized and integrated through an interactive view of the origins of dental anxiety. A multitude of factorsreflecting both personal and family attitudes, early experiences, and dispositional variables -appear to interact to determine the child's initial level of situational
TABLE 4 CORRELATIONS BETWEEN PSPQ SCORES AND CHILDREN'S RESPONSES TO DENTAL STRESS Heart Rate
Guilt vs. Socialized Maturity Security vs. Insecurity Satisfaction vs. Dissatisfaction Aggressiveness vs. Placidity Hostile Aggressiveness vs. Fearfulness Indulged Compliance vs. Anxious Rebelliousness Anxious Depressiveness vs. Non-Anxious Confidence Passive Withdrawal vs. Sociality Adventurous Maturity vs. Cautious Immaturity Dominant Independence vs. Timid Dependence Trustful Optimism vs. Misanthropic Pessimism Self-Distrust vs. Self-Confidence Self-Accepting Dominance vs. Self-Rejecting Submissiveness
Clinical Anxiety
.64*** -.4 7 *
-.76*** .83*** -.39*
.35* .44*
.45* .09
-.53* -.23
-.46* .47**
.09 -.5 1* *
.53** -.29
p
role of basic personality factors such as trait anxiety, neuroticism, introversion, or dependency.4'5 Other workers have contended that dental fears are largely acquired, and represent responses conditioned by familial attitudes and/or a previous, unpleasant experience.6-8 Several retrospective studies of dentallyJ Dent Res 58(11):2046-2051, November 1979 anxious adults have been conducted, using interview and questionnaire approaches. 4,6,7,12 These studies identify traumatic Introduction. dental experience during childhood as one primary factor in the acquisition of negaThe recent pedodontic literature reflects tive dental attitudes. Reports of unfavora growing concern with the problem of able attitudes toward dentistry among childhood dental anxiety. Most young family members were also found more children experience some anxiety in their frequently in fearful than nonfearful adults. initial dental contacts, but wide individual Findings regarding the importance of paindifferences are apparent. The variability in ful experience and negative family attitudes children's dental anxiety has been well- support the usefulness of viewing dental described by Swallow.1 At one extreme fears as learned responses to the stimuli are those happy and relaxed children who intrinsic to the dental context. However, readily accept any form of dental treatment; these findings do not preclude the potential at the other are those extremely fearful chil- importance of personality traits in modudren who resist every form of treatment lating the learning process. For example, offered. Anxious children demand consider- Forgione and Clark,1 3 re-analyzing Shoben able dedication and expertise in child and Borland's6 data, reported that low pain management techniques from the dental tolerance and high trait anxiety were further staff. For effective management of the important contributors to odontophobia. young pedodontic patient, an understand- Lautch4 also noted that neurotic traits in ing of the etiology of children's stress re- childhood were an additional predisposing sponses is vitally needed. factor in the development of dental phobia. Existing theories of the origins of dental Longitudinal prospective studies of childanxiety are largely speculative, represent- hood dental anxiety have only recently ing untested extrapolations from the psy- begun to emerge.9-1 1 Initial results from choanalytic, personality, or behavioristic these projects suggest that dental anxiety literatures. Psychoanalytically-oriented work- is a dynamic phenomenon, which evolves ers have stressed the special significance in a complex and variable manner as dental of the oral zone.2,3 Some authors, noting experience accumulates. the large variability among children in Sermet5 and Shaw14 collaboratively anxiety manifestations, have emphasized the studied 100 dentally-anxious and 100
Responses to dental stress were evaluated in 26 preschool children during an initial examination visit. Measures of the children's developmental status and personality were collected during a home visit. Significant relationships emerged which suggest that personality development influences children's ability to tolerate dental stress.
Received for publication December 11, 1978. Accepted for publication January 18, 1979.
This research was partially supported by Grant No. lR23-DE03891-02 from the National Institute of Dental Research.
2046 Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
Vol. 58 No. II
PRESCHOOL PERSONA LITY AND DENTAL
STRESS
2047
dentally non-anxious children. Emotional who independently viewed videotapes of attributes and medical and dental histories the visits. A six-point rating scale (Table 1) of the children and their parents were was used to score each visit period. The assessed by parental interviews and question- judges' ratings for each period were avernaires. Dental anxiety emerged as a complex aged, and these period scores averaged to phenomenon which reflects multiple inter- yield a mean anxiety rating for each visit. acting variables. Significant differences be- Pre-training of the judges ensured intertween the two groups of children were rater reliabilities exceeding .80. Following the dental visit, a trained found in their introductions to dentistry, their dental experiences, and their mothers' researcher visited the child's home for a dental attitudes and experiences.14 Medical 90-minute period. Developmental, personand emotional factors also differentiate ality, and child-rearing data were collected; the two groups. Behavioral or emotional the child-rearing data are reported elsedisorders were found in 31% of the dental- where.5 ly-anxious children, but in only 6% of the TABLE 1 non-anxious children. A generally nervous RATING SCALE ANXIETY CLINICAL or high-strung disposition was described for 54% of the dentally-anxious children, but for none of the non-anxious subjects.5 The findings reviewed above strongly 0. Relaxed, smiling, willing and able to converse. During stressful procedure, implicate basic personality factors in the 1. Uneasy, concerned. may protest briefly and quietly to indicate etiology of dental anxiety. This study was discomfort. Hands remain down or partially undertaken to further clarify the relationraised to signal discomfort. Child willing and ship between developmental-personality able to interpret experience as requested. variables and the preschool child's response Tense facial expression, may have tears in to dental stress. eyes. 2. Child appears scared. Tone of voice, questions
Materials and methods.
The subjects were 26 children, aged three-to-five years, with no prior dental experience. The children were participants in a longitudinal project assessing children's responses to sequential dental visits. The study sample was established by including all three-to-five-year-olds who enrolled in the longitudinal project during a consecutive six-week period. All subjects had uneventful medical histories and were not receiving any medication. Each child's response to dental stress was assessed during his/her initial dental examination visit. This visit was divided into three periods corresponding to the mirror and explorer exam, prophylaxis, and topical fluoride application. Data collected included heart rate and clinical anxiety ratings. Heart rate was recorded using a photoelectric sensor clipped to the child's finger and was converted to beat-to-beat HR data via a biotachometer. HR was sampled for a 99-beat interval at the outset of each visit period. A mean HR value for the visit was obtained by averaging all beat-to-beat HR samples. Clinical anxiety ratings were made by three judges, naive to the study purposes,
and answers reflect anxiety. During stiessful procedure, verbal protest, (quiet) crying, hands tense and raised (not interfering much - may touch dentist's hand or instrument, but not pull at it). Child interprets situation with reasonable accuracy, and continues to work to cope with his/her anxiety. 3. Shows reluctance to enter situation, difficulty in correctly assessing situational threat. Pronounced verbal protest, crying. Using hands to try to stop procedure. Protest out of proportion to threat. Copes with situation with great reluctance. 4. Anxiety interferes with ability to assess situation. General crying not related to treatment. More prominent body movement. Child can be reached through verbal communication, and eventually, with reluctance and great effort, he/she begins the work of coping with the threat. 5. Child out of contact with the reality of the threat. General loud crying, unable to listen to verbal communication, makes no effort to cope with threat. Actively involved in escape behavior. Physical restraint required.
Developmental measures included the Denver Developmental Screening Test, the Peabody Vocabulary Test, and the Vineland Social Maturity Scale. The Denver Developmental Screening Test (DDST)16 is a standardized instrument for detecting children
Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
2048
J Dent Res November 1 9 79
VENHAMETAL.
with significant social, language, or motor delays. A series of developmental tasks and milestones are surveyed to classify the child's progress as either normal or delayed. The Peabody Picture Vocabulary Test (PPVT)17 is a reliable, easily-administered test of verbal intelligence. The test consists of a graduated series of plates, each containing four pictures; the subject points to the picture matching each spoken stimulus word. Raw PPVT scores are converted into mental ages, standard-score intelligence quotients, and percentile ranks. The Vineland Social Maturity Scale (VSMS)1 8 is a rapidly-administered checklist measuring the child's progress toward independence and social competence. Scoring is based on parental report. Raw scores can be converted into social ages and social quotients. Personality data were collected using the Preschool Personality Questionnaire and the Self-Concept and Motivation Inventory. The Preschool Personality Questionnaire (PSPQ)19,20 consists of a series of twochoice questions verbally administered to the preschool child. Sample questions include, "Would you rather (a) color a book, or (b) climb a tree?" and "Do you like to (a) keep your room neat and clean, or (b) mess it up?" Responses were analyzed to yield scores on 13 personality dimensions. The Self-Concept and Motivation Inventory (SCMI)21 is a 24-item pictorial rating scale available in a verbally-administered preschool version. Each question poses a hypothetical situation to which the child responds by selecting one of three faces. A sample question is, "What face would you wear if you had done something that would get you a spanking?" Pilot work indicated that children participated more eagerly when age-appropriate cartoon figures were substituted for the original stylized line drawings (Figure 1). Responses yield a Self-Concept factor, subdivided into SelfAdequacy and Role Expectation, and a Motivation factor, subdivided into Achievement Need and Failure Avoidance. Tasks administered to the child were presented as a game and conducted in a relaxed manner. To maintain the child's optimal cooperation, interviewing was periodically interrupted to provide an opportunity for a more physically-active task. Statistical analyses were performed to evaluate relationships between the dental
stress measures and the developmental and personality variables. Heart rate data were analyzed using the Pearson product-moment coefficient, a parametric correlational statistic. Clinical anxiety ratings were analyzed via a non-parametric statistic, the Spearman correlation coefficent.
Results. Developmental variables. - Developmental status assessed by the DDST was not significantly related either to heart rate or clinical anxiety. However, scores on the PPVT and VSMS were inversely related to the dental stress indices (Table 2). Percentile rank on the PPVT was negatively correlated with heart rate, whereas social age and social quotient on the VSMS were negatively correlated with both heart rate and clinical anxiety. TABLE2 CHILDREN'S DEVELOPMENTAL STATUS AND RESPONSES TO DENTAL STRESS
PPVT
Heart Rate Clinical Anxiety
Mental Age Intelligence Quotient Percentile Rank
-.29 -.23 -.39*
-.20 -.09 -.18
-.39* -.47**
.44* -.44*
VSMS
Social Age Social Quotient *p < .05 **p < .01
TABLE3
CORRELATIONS BETWEEN SCMI SCORES AND CHILDREN'S RESPONSES TO DENTAL STRESS
Heart Rate
Self-adequacy Role Expectation Self-Concept Achievement Need Failure Avoidance Motivation *
-.63*** -.67*** -.67*** .29 .46* .44 *
Clinical Anxiety -.80*** -.77*** -.85*** .44* .73*** .64***
p < .05
**p < .01 *
p < .001
Personality variables. - Relationships between the SCMI factors and the dental
Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
Vol. 58 No. 11
PRESCHOOL PERSONALITY AND DENTAL STRESS
stress measures are presented in Table 3. Lower scores on the Self-Adequacy, Role Expectation, and Self-Concept factors were associated with higher heart rates and anxiety ratings. Higher scores on Achievement Need, Failure Avoidance, and Motivation were associated with more anxious dental responses. Personality factors tapped by the PSPQ also bore strong relationships to the children's responses under dental stress (Table 4). Personality traits associated with higher heart rates and/or clinical anxiety scores included: guilt, insecurity, dissatisfaction, aggressiveness, fearfulness, anxious rebelliousness, anxious depressiveness, passive withdrawal, cautious immaturity, misanthropic pessimism, self-distrust, and self-rejecting
submissiveness.
Discussion. The results of this investigation confirm the role of basic developmental and personality factors in the etiology of childhood dental anxiety. In the absence of previous dental experience, the subjects showed
a wide spectrum of responses to the dental visit. Furthermore, the nature of the child's response to dental stress was strongly related to basic dimensions of personality development. Children who were relatively delayed in social and language development tended to exhibit a more anxious response to the dental visit. Perhaps these children were unable to fully comprehend and realistically appraise the nature of dental treatment, or to understand explanations and instructions. Such deficits in realistically appraising the stresses inherent to the dental context may have predisposed these children to magnify the degree of threat and, consequently, to experience greater anxiety. It is also plausible that the developmentallyslower children had fewer skills and resources available for coping with the actual stresses of dental procedures. Certain personality traits also seemed to predispose children to respond anxiously on their first exposure to the dental situation. The present results are compatible with, and extend previously-cited, findings,
What Face Would You Wear? Sample
2049
/P
£L
ORIGINAL STIMULI FOR THE SCMI
CARTOON FIGURES USED AS SCMI STIMULI IN THE PRESENT STUDY
Fig. 1 -Original and revised stimuli for the Self-Concept and Motivation Inventory
(SCMI).
Downloaded from jdr.sagepub.com at Freie Universitaet Berlin on May 9, 2015 For personal use only. No other uses without permission.
2050
VENHAM ETAL.
suggesting that ability to tolerate dental stress is at least partially mediated by personality factors, such as trait anxiety and introversion. Greater dental anxiety was associated with SCMI and PSPQ scores indicative of lower self-adequacy and selfconcept, and higher guilt, self-distrust, and self-rejection. These results suggest that children with lower self-esteem respond less favorably to dental stress. More anxious dental responses were also shown by children with scores indicative of insecure, fearful, anxious-rebellious, or anxiousdepressive personality dispositions. Such findings suggest that, as might be expected, children who are generally more anxious tend to exhibit greater situational stress. Finally, higher heart rates and/or anxiety ratings were correlated with personality dispositions of passive withdrawal, cautiousness, pessimism, and avoidance of failure. Thus, it appears that children who are less willing to act and take risks experience greater dental anxiety.
J Dent Res November 1 9 79
Conclusions. Our investigation strongly supports the notion that the young patient brings to the initial dental experience internal characteristics which may either facilitate or impede his/her adaptation to this stress. Certain developmental and personality characteristics may predispose the young dental patient to perceptually distort the degree of threat present, and to unrealistically interpret the amount of discomfort actually experienced. Our findings, therefore, do not support the belief that dental anxiety is solely or primarily a conditioned response to past traumatic dental experiences. Rather, we believe that the literature, to date, can be organized and integrated through an interactive view of the origins of dental anxiety. A multitude of factorsreflecting both personal and family attitudes, early experiences, and dispositional variables -appear to interact to determine the child's initial level of situational
TABLE 4 CORRELATIONS BETWEEN PSPQ SCORES AND CHILDREN'S RESPONSES TO DENTAL STRESS Heart Rate
Guilt vs. Socialized Maturity Security vs. Insecurity Satisfaction vs. Dissatisfaction Aggressiveness vs. Placidity Hostile Aggressiveness vs. Fearfulness Indulged Compliance vs. Anxious Rebelliousness Anxious Depressiveness vs. Non-Anxious Confidence Passive Withdrawal vs. Sociality Adventurous Maturity vs. Cautious Immaturity Dominant Independence vs. Timid Dependence Trustful Optimism vs. Misanthropic Pessimism Self-Distrust vs. Self-Confidence Self-Accepting Dominance vs. Self-Rejecting Submissiveness
Clinical Anxiety
.64*** -.4 7 *
-.76*** .83*** -.39*
.35* .44*
.45* .09
-.53* -.23
-.46* .47**
.09 -.5 1* *
.53** -.29
p
