Use of Filmed Modeling to Reduce Uncooperative Behavior of Children During Dental Treatment BARBARA G. MELAMED, ROLAND R. HAIVES, ELAIN\E HEIBY, and JOHN GLICK Psychology Department and Department of Pedodontics, School of Dentistry, Case Western Reserve University, Cleveland, Ohio 44106, USA
Sixteen inner city children attending a pedodontic clinic were shown either a filmed demonstration of a child model cooperatively undergoing dental treatment or a film unrelated to dental activity. The group viewing the modeling film showed significantly fewer disruptive behaviors during restorative care and were rated as less fearful than the control group. Many articles in dental literature advocate methods for reducing a child's anxiety about dental treatment. Alleviating a child's anxiety about dental treatment is important not only in mitigating the immediate fear but also in preventing apprehension continuing into adulthood. Sympathetic understanding on the dentist's part is commonly recommended, suggesting that the dentist should have patience and tolerance of the child's needs.' Cherches and Blackman2 stressed the importance of home preparation for the dental visit; friendly greetings from the dentist and assistants; the use of books, movies, and slides as distracting entertainment; use of the "tell, show, do method;" and premedication if necessary. Croxton3 concluded that overpermissiveness is one cause of children's management problems after showing that firm, consistent discipline increased positive behavior during the dental procedure. Children in the age groups 2 to 9 years are reported by pedodontists to require more vigorous physical behavioral management procedures than other age groups.4 Christen5 recommended that the child patient mentally rehearse the impending dental treatment based on an accurate description of what he is about to exReceived for publication July 8, 1974. Accepted for publication November 21, 1974.
perience. He suggested that a child's first visit to a dentist should involve nothing more than an introduction to the dental operatory and an explanation of the equipment and procedure. When a child is a management problem premedication is sometimes used.6 Whereas sedation typically alleviates immediate anxiety and uncooperative behavior, there is much controversy concerning its use and the complications of side effects. Premedication does not eliminate fear; rather, it may forestall attempts to teaclh coping behavior by limiting subject arousal. Social learning theory predicts that fear response patterns in children can be vicariously extinguished by observing a model undergoing the feared stimulus without experiencing negative consequences.7 Several studies have demonstrated the effective use of therapeutic modeling to reduce children's anxiety concerning dogs, snakes, and water.8-10 In the dental situation, case studies in which a live peer model was used to demonstrate positive behavior during dental treatment lhave succeeded in reducing the uncooperative behavior of fearful children"1'2 In a well-controlled experiment comparing the effectiveness of desensitization and filmed modeling, Johnson and Machen13 found both techniques to be equally successful in reducing the fearful child's anxiety about the dental procedure. However, Sawtell et al14 found that a placebo condition where children interacted with a friendly hygienist about matters unrelated to dentistry was as effective as either desensitization or filmed modeling. These earlier studies have not included a number of factors which lead to optimal imitation such as coping behavior of the 797
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MELAMED ET AL
model, rewarding consequences to the model, and the presentation of the model under a condition of subject arousal.7 The purpose of this study was to determine if a modeling film presented under optimal conditions was more effective than an unrelated film in reducing children's anxiety and uncooperative behavior during dental treatment. Relationships between maternal anxiety, the level of anxiety of the child patient, and disruptive behavior in the dental chair were investigated.
Materials and Methods Sixteen inner city children with no previous dental experience were selected from the dental population of the Pedodontic Clinic of Rainbow Babies and Childrens Hospital in Cleveland, Ohio. The patients ranged in age from 5 to 11 years. No physically handicapped or mentally retarded children were included in the study. The children were randomly assigned to the experimental modeling group or to the control group. Both groups were matched according to age, sex, socioeconomic status, and initial scores on the modified Children's Fear Survey Schedule (CFSS) with dentalspecific items included.15 Each child was seen for at least two visits to the clinic. Appointments were scheduled for further visits if more restorative care was necessary. The first clinic visit consisted of two treatment sessions. At the first of these sessions, a prophylaxis was performed by the hygienist. At the second session during this first clinic visit the dentist examined the teeth. The third treatment session, approximately one week later, involved the restoration of at least one carious tooth. On arrival for the first clinic visit, the mother completed a maternal anxiety questionnaire, adapted from Baldwin and Johnson,16 and a patient consent form. Meanwhile the child was given the CFSS and the Palmar Sweat Index (PSI) 17 before being observed for overt fearful responses while with the hy-
gienist. The PSI is a physiological measure of arousal level that is applicable to children.18 A behavior profile rating adapted from Melamed et al19 was used to measure objectively the children's responses that indicated anxiety during the prophylaxis and examination by the dentist. This profile in-
J Dent Res July-August 1975
cludes categories such as crying, refusal to open the mouth, white knuckles, rigid posture, verbal complaints, and kicking. The frequency of such behaviors was rated by an independent observer unaware of group assignments and the categories were weighted according to the degree of disruption. During the second visit to the clinic, each child viewed either an experimental modeling film or a control film before he entered the dental operatory for restorative treatment. The 13-minute experimental videotape showed an initially fearful 4-year-old black child experiencing a typical dental procedure with a sensitive and friendly dentist. The child was shown coping with his anxiety and clearly discovering that there was nothing to fear. The child model was verbally reinforced for this cooperation and was given a toy at the end of the procedure. The control film, which was of comparable length, portrayed a similar young black child involved in activities unrelated to dentistry. The CFSS was administered to all subjects in both control and experimental groups before any dental treatment. The PSI was recorded before and after the children viewed the films and again after the dental treatment. The child's fearful and uncooperative behavior during restorative treatment was rated on the behavior profile rating. The dentist and the observer independently rated the fear and cooperation of each patient on a ten-point scale immediately after each session. The interrater reliability for the behavior profile was 0.99 (Spearman Brown) and 0.95 for the PSI. Correlational analysis between dentist's and observer's ratings concerning fear and cooperation yielded significance (P < 0.001) for all sessions. Results To determine the difference between the experimental modeling and the control group, the PSI, behavior profile rating, and the CFSS, scores were analyzed by a repeated measures analyses of variance. The analysis for the behavior profile rating is presented in the table. In the between subjects analysis, the modeling group's mean score (2.67) on the behavior profile rating of disruptive behavior, averaged for the three treatment sessions, was significantly lower than the
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FILMED MODELING TO AID BEHA VIOR
Vol 54 No. 4
799
TABLE REPEATED MEASURES ANALYSIS OF VARIANCE FOR BEHAVIOR PROFILE RATING FREQUENCY OF DISRUPTIVE BEHAVIORS PER THREE-MINUTE INTERVAL Source of Variance
df
MS
Between subjects Group Error Within subjects
15 1 14
102.61 24.89
4.12
0.059
63.52 56.57 14.01
4.53 4.04
0.019 0.028
Sessions
32 2
Group x session Error
2 28
P-value
47
Total
mean score (5.59) of the control group (F=4.12; df= 1/14; P
Sixteen inner city children attending a pedodontic clinic were shown either a filmed demonstration of a child model cooperatively undergoing dental treatment or a film unrelated to dental activity. The group viewing the modeling film showed significantly fewer disruptive behaviors during restorative care and were rated as less fearful than the control group. Many articles in dental literature advocate methods for reducing a child's anxiety about dental treatment. Alleviating a child's anxiety about dental treatment is important not only in mitigating the immediate fear but also in preventing apprehension continuing into adulthood. Sympathetic understanding on the dentist's part is commonly recommended, suggesting that the dentist should have patience and tolerance of the child's needs.' Cherches and Blackman2 stressed the importance of home preparation for the dental visit; friendly greetings from the dentist and assistants; the use of books, movies, and slides as distracting entertainment; use of the "tell, show, do method;" and premedication if necessary. Croxton3 concluded that overpermissiveness is one cause of children's management problems after showing that firm, consistent discipline increased positive behavior during the dental procedure. Children in the age groups 2 to 9 years are reported by pedodontists to require more vigorous physical behavioral management procedures than other age groups.4 Christen5 recommended that the child patient mentally rehearse the impending dental treatment based on an accurate description of what he is about to exReceived for publication July 8, 1974. Accepted for publication November 21, 1974.
perience. He suggested that a child's first visit to a dentist should involve nothing more than an introduction to the dental operatory and an explanation of the equipment and procedure. When a child is a management problem premedication is sometimes used.6 Whereas sedation typically alleviates immediate anxiety and uncooperative behavior, there is much controversy concerning its use and the complications of side effects. Premedication does not eliminate fear; rather, it may forestall attempts to teaclh coping behavior by limiting subject arousal. Social learning theory predicts that fear response patterns in children can be vicariously extinguished by observing a model undergoing the feared stimulus without experiencing negative consequences.7 Several studies have demonstrated the effective use of therapeutic modeling to reduce children's anxiety concerning dogs, snakes, and water.8-10 In the dental situation, case studies in which a live peer model was used to demonstrate positive behavior during dental treatment lhave succeeded in reducing the uncooperative behavior of fearful children"1'2 In a well-controlled experiment comparing the effectiveness of desensitization and filmed modeling, Johnson and Machen13 found both techniques to be equally successful in reducing the fearful child's anxiety about the dental procedure. However, Sawtell et al14 found that a placebo condition where children interacted with a friendly hygienist about matters unrelated to dentistry was as effective as either desensitization or filmed modeling. These earlier studies have not included a number of factors which lead to optimal imitation such as coping behavior of the 797
Downloaded from jdr.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 2, 2015 For personal use only. No other uses without permission.
798
MELAMED ET AL
model, rewarding consequences to the model, and the presentation of the model under a condition of subject arousal.7 The purpose of this study was to determine if a modeling film presented under optimal conditions was more effective than an unrelated film in reducing children's anxiety and uncooperative behavior during dental treatment. Relationships between maternal anxiety, the level of anxiety of the child patient, and disruptive behavior in the dental chair were investigated.
Materials and Methods Sixteen inner city children with no previous dental experience were selected from the dental population of the Pedodontic Clinic of Rainbow Babies and Childrens Hospital in Cleveland, Ohio. The patients ranged in age from 5 to 11 years. No physically handicapped or mentally retarded children were included in the study. The children were randomly assigned to the experimental modeling group or to the control group. Both groups were matched according to age, sex, socioeconomic status, and initial scores on the modified Children's Fear Survey Schedule (CFSS) with dentalspecific items included.15 Each child was seen for at least two visits to the clinic. Appointments were scheduled for further visits if more restorative care was necessary. The first clinic visit consisted of two treatment sessions. At the first of these sessions, a prophylaxis was performed by the hygienist. At the second session during this first clinic visit the dentist examined the teeth. The third treatment session, approximately one week later, involved the restoration of at least one carious tooth. On arrival for the first clinic visit, the mother completed a maternal anxiety questionnaire, adapted from Baldwin and Johnson,16 and a patient consent form. Meanwhile the child was given the CFSS and the Palmar Sweat Index (PSI) 17 before being observed for overt fearful responses while with the hy-
gienist. The PSI is a physiological measure of arousal level that is applicable to children.18 A behavior profile rating adapted from Melamed et al19 was used to measure objectively the children's responses that indicated anxiety during the prophylaxis and examination by the dentist. This profile in-
J Dent Res July-August 1975
cludes categories such as crying, refusal to open the mouth, white knuckles, rigid posture, verbal complaints, and kicking. The frequency of such behaviors was rated by an independent observer unaware of group assignments and the categories were weighted according to the degree of disruption. During the second visit to the clinic, each child viewed either an experimental modeling film or a control film before he entered the dental operatory for restorative treatment. The 13-minute experimental videotape showed an initially fearful 4-year-old black child experiencing a typical dental procedure with a sensitive and friendly dentist. The child was shown coping with his anxiety and clearly discovering that there was nothing to fear. The child model was verbally reinforced for this cooperation and was given a toy at the end of the procedure. The control film, which was of comparable length, portrayed a similar young black child involved in activities unrelated to dentistry. The CFSS was administered to all subjects in both control and experimental groups before any dental treatment. The PSI was recorded before and after the children viewed the films and again after the dental treatment. The child's fearful and uncooperative behavior during restorative treatment was rated on the behavior profile rating. The dentist and the observer independently rated the fear and cooperation of each patient on a ten-point scale immediately after each session. The interrater reliability for the behavior profile was 0.99 (Spearman Brown) and 0.95 for the PSI. Correlational analysis between dentist's and observer's ratings concerning fear and cooperation yielded significance (P < 0.001) for all sessions. Results To determine the difference between the experimental modeling and the control group, the PSI, behavior profile rating, and the CFSS, scores were analyzed by a repeated measures analyses of variance. The analysis for the behavior profile rating is presented in the table. In the between subjects analysis, the modeling group's mean score (2.67) on the behavior profile rating of disruptive behavior, averaged for the three treatment sessions, was significantly lower than the
Downloaded from jdr.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 2, 2015 For personal use only. No other uses without permission.
FILMED MODELING TO AID BEHA VIOR
Vol 54 No. 4
799
TABLE REPEATED MEASURES ANALYSIS OF VARIANCE FOR BEHAVIOR PROFILE RATING FREQUENCY OF DISRUPTIVE BEHAVIORS PER THREE-MINUTE INTERVAL Source of Variance
df
MS
Between subjects Group Error Within subjects
15 1 14
102.61 24.89
4.12
0.059
63.52 56.57 14.01
4.53 4.04
0.019 0.028
Sessions
32 2
Group x session Error
2 28
P-value
47
Total
mean score (5.59) of the control group (F=4.12; df= 1/14; P
