Children’s dental fear and anxiety: exploring family related factors

Children’s dental fear and anxiety: exploring family related factors Background: Dental fear and anxiety (DFA) is a major issue affecting children’s oral health and clinical management. This study investigates the association between children’s DFA and family related factors, including parents’ DFA, parenting styles, family structure (nuclear or single-parent family), and presence of siblings. Methods: A total of 405 children (9–13 years old) and their parents were recruited from 3 elementary schools in Hong Kong. Child’s demographic and family-related information was collected through a questionnaire. Parents’ and child’s DFA were measured by using the Corah Dental Anxiety Scale (CDAS) and Children Fear Survey Schedule- Dental Subscale (CFSS–DS), respectively. Parenting styles were gauged by using the Parent Authority Questionnaire (PAQ). Results: DFA was reported by 33.1% of children. The mean (SD) CFSS-DS score was 29.1 (11.0). Children with siblings tended to report DFA (37.0% vs. 24.1%; p = 0.034) and had a higher CFSS-DS score (29.9 vs. 27.4; p =0.025) as compared with their counterpart. Children from single-parent families had lower CFSS-DS score as compared with children from nuclear families (β = − 9.177; p = 0.029). Subgroup analysis showed a higher CFSS-DS score among boys with siblings (β =7.130; p = 0.010) as compared with their counterpart; girls’ from single-parent families had a lower CFSS-DS score (β = − 13.933; p = 0.015) as compared with girls from nuclear families. Children’sDFA wasnotassociated with parents’ DFA or parenting styles (p >0.05). Conclusions: Family structure (nuclear or single-parent family) and presence of siblings are significant determinants for children’s DFA. Parental DFA and parenting style do not affect children’s DFA significantly. Keywords: Dental fear, Dental anxiety, Children, Parents, Parenting styles, Family factors Background acquisition in childhood may track into adulthood and is Dental fear and dental anxiety (DFA) refer to the strong a significant predictor for dental avoidance in adulthood negative feelings associated with dental treatment, [6, 7]. Preventing and intercepting DFA during whether or not the criteria for a diagnosis of dental pho- childhood is considered as a critical approach for im- bia are met [1]. The reported prevalence of DFA among proving people’s oral health and dental experience [5]. children and adolescents in different countries ranged It was speculated that parents’ DFA might exerts an from 5 to 33% [1–4]. Children with DFA often try all influence on their children’s DFA through modeling and means to avoid or delay dental treatment, resulting in information [8]. Many adults with DFA may verbalize deterioration of their oral health [5]. They also their fearful feelings in front of their children, creating a demonstrate poor cooperation during dental visits, negative impression on dental treatment [5]. Most which compromises the treatment outcomes, creates oc- children at early school age begin to emulate their par- cupational stress on dental staff, and causes discord be- ents who are looked upon as models [9]. They are very tween dental professionals and their parents [1]. DFA likely to internalize their parents’ values, attitudes and worldviews, which would gradually become a part of * Correspondence: gaoxl@hku.hk their own belief system [9]. There is moderate evidence Dental Public Health, Faculty of Dentistry, The University of Hong Kong, 3rd to support the relationship between parental and child Floor, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong DFA [10]. An American study reported that over 40% of Kong Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wu and Gao BMC Oral Health (2018) 18:100 Page 2 of 10 parents/guardians gave their children negative connota- factors, namely parents’ DFA, parenting styles, family tion about their previous dental visit [11]. This study structure (single-parent or nuclear family), and presence also showed a shared anxiety between parents/guardians of siblings. and their children, thus suggesting that parents played a key role in children’s anxiety and fear development. Methods In another study, parental dental anxiety was demon- Sample size calculation strated as a significant indicator for children’sdental The sample size was calculated by using G*Power anxiety (β = 0.244; p = 0.016) [12]. Despite the poten- version 3.1.9.2. Targeting a statistical power of 0.9 and a tial influence of parents, consensus is lacking regard- significant level of 0.05 and estimating 13.5% children ing whether mother or father plays a more significant have DFA [25], 373 subjects are needed to detect an role in children’s DFA. A previous study concluded effect size of 0.5. that fathers deliver major information, such as danger, to children and play a mediating role for the transfer Participant recruitment of dental fear from parents to children [13]. However, The protocol of this study was reviewed by the Institu- another study showed no significant difference be- tional Review Board (IRB) of the University of Hong tween the influence of mothers and fathers on their Kong/Hospital Authority Hong Kong West Cluster. An children’sDFA [14]. ethical approval was obtained (#UW16–130). Parenting styles provided an environmental framework A list of government-funded elementary schools was for children’s psychosocial growth and were assumed to retrieved from the official website of the Education shape children’s behaviors [15]. Baumrind identified Bureau, Hong Kong Special Administrative Region three main styles of parenting, namely authoritative, (http://www.edb.gov.hk). Among a total of 454 schools, 5 authoritarian, and permissive [16]. This classification of were randomly selected and approached. Three out of the 5 parenting styles has served as a useful tool for investigat- elementary schools participated. Child-mother-father ing the influence of parenting on various issues concern- triads were recruited. The inclusion criteria were: (i) ing child development [16]. The relationship between the school was a government-funded, co-educational parenting styles and children’s dental fear has attracted school (i.e. mixed-sex school); (ii) the child was en- some scholarly attention. A study measured parents’ rolled in Primary 4–6 of a participating school; (iii) child-rearing attitudes and found that the subscale the child was 9–13 years old; and (iv) the child and self-complaints (example item “My child’s happiness his/her both parents were literate and were able to needs a lot of sacrifice on my part”) were associated with complete questionnaires themselves. Children with se- children’s dental fear [17]. However, another study found vere systemic diseases or physical or psychological no association between parenting styles and dental anx- disabilities were excluded. All eligible children in the iety of children [18]. With limited evidence gleaned from participating schools were approached. Children with very few studies, the association between parenting informed written consent from both parents were styles and children’s DFA remains ambiguous. recruited. In addition, a family dynamics model revealed that birth order could influence one’s personality and behav- ior [19]. It has been reported that children’s birth order Questionnaires partially determines their ability to cope with stresses in Each participating family was asked to complete a set of medical situations [20]. In the dental setting, only born four questionnaires. The questionnaires were distributed children and first-born children were found to have a via class teachers and were completed by the higher clinical situational DFA and were less cooperative participants at home on a self-administered basis. Clear than others [21, 22]. A study involving children of vari- instructions were given to avoid confusion. All question- ous age showed that more children reported to have naires were completed anonymously. Each participating DFA if their siblings reported DFA [23]. However, no as- family was identified with a code and their names were sociation was found between children’s DFA and the not disclosed. The questionnaires were pretested among number of children in their families in another study 6 families with diverse background to ensure relevance [24]. The current evidence concerning how birth order and clarity. Completing the questionnaires took approxi- and presence of siblings are associated with children’s mately 20 min. DFA remains scarce and inconsistent findings have been The first questionnaire, completed by parents, reported. collected information on the child’s demographic back- In view of the currently insufficient and contradictory ground (age, gender, and birth place), family socioeco- evidence, this study aimed to investigate the association nomic status (family income, parents’ education levels, between children’s DFA and a variety of family related parents’ occupation, and housing condition), family Wu and Gao BMC Oral Health (2018) 18:100 Page 3 of 10 structure (single-parent or nuclear family), presence of with a total CFSS-DS score below 32 are considered sibling, and the birth order of the child. non-fearful; 32–39 is defined as moderate fearful; > 39 is The second questionnaire was the Parental Authority defined as fearful [31]. CFSS-DS is deemed one of the Questionnaire (PAQ); a psychometric scale that assesses most commonly used psychological scales for children. the authoritativeness, authoritarianism and permissive- A Chinese version of CFSS-DS [32] was used in this ness practiced by fathers and mothers, respectively, in study and was completed by the child him/herself. The rearing their children. This study used a short version test-retest reliability (intraclass correlation) of CFSS-DS comprising 20 items, which was adapted from the Buri’s was 0.71 and the internal consistency (Cronbach’s alpha) 30-item PAQ and showed adequate validity and internal was 0.85 [33]. The validity was good; higher mean consistency in children [26]. Test-retest reliability (the CFSS-DS scores were found in children who were de- intraclass correlation) of Buri’s PAQ were 0.77–0.92 and fined as uncooperative by using the Frankl Scale (stan- internal consistency (Cronbach alpha) were 0.74–0.87 dardized mean difference = 1.15; p < 0.01) [33]. All scales [27]. The validity was adequate; authoritarianism was in- used can be found in Additional file 1. versely related to permissiveness (mother: r = − 0.38; father: r = − 0.50; all p < 0.0005) and authoritativeness Statistical analysis (mother: r = − 0.48; father: r = − 0.52; all p < 0.0005) and The data analysis was performed by using Statistical permissiveness was not significantly related to authorita- Package for Social Sciences (SPSS) version 23.0. Partici- tiveness (mother: r = 0.07; father: r = 0.12; all p > 0.10) pants’ socio-demographic profile and family related fac- [27]. The Chinese version of PAQ was adopted [28]. tors were described. Parametric and non-parametric There were 7 items for authoritativeness, 7 for authori- tests were used for comparing means/medians, whereas tarianism, and 6 for permissiveness. Responses to each Chi-square tests were used for comparing proportions. item are made on a 5-point Likert scale, ranging from Multiple linear regression models were constructed to “strongly disagree” to “strongly agree”. The total score test the associations after controlling for possible con- for each parenting style was calculated by summing founders. The collinearity among independent variables scores of items in the corresponding parenting style. has been tested. In order to avoid possible collinearity, Among the three parenting styles (authoritative, authori- “mother’s education” and “father’s education” were con- tarian and permissive), the one with the highest mean verted to “parental education”, defined as education level score was regarded as the dominant parenting style for of mother or father, whichever is lower. The same con- that parent. The PAQ was completed by the child him/ version applied to “parental occupation”. After such con- herself, as instructed. versions, collinearity was ruled out because all the values The third questionnaire was Corah Dental Anxiety of tolerance were well above 0.2. The stratified analysis Scale (CDAS) for measuring parents’ DFA. CDAS has by gender was also carried out to test the associations in been widely used in research studies and its reliability, boys and girls, respectively. validity and usefulness have been documented [29]. The test-retest reliability (correlation coefficient) was 0.82 Results and the internal consistency (Kuder-Richardson For- Socio-demographic profile, family related factors and mula) was 0.86. The validity was moderate as shown by parenting styles the correlations between the dentists’ ratings and the pa- Among 881 eligible families approached, 405 partici- tients’ test scores. The scale was later translated into pated and returned the questionnaires. The response Chinese [30]. CDAS contains 4 items, where respon- rate was 46.0%. Most (71.0%) children were 10–11 year-- dents choose a score closest to their respective dental old, with some 9 year-olds and 12–13 year-olds (Table 1). situations. The score ranged from 1 (not anxious) to 5 There were 188 (46.7%) boys and 215 (53.3%) girls. Most (extremely anxious). The total score for 4 items ranges (90.3%) of them were born in Hong Kong. Around from 4 to 20, with a higher score indicating a higher two-thirds (62.7%) of mothers were in the age group of DFA level. The anxiety level was classified as “low” 35–44 and two-thirds (60.7%) of fathers were 45 or (scores below 9), “moderate” (scores from 9 to 12), above. Two-thirds (69.5%) of families had a moderate “high” (scores from 13 to 14), and “severe” (scores from monthly income (HKD 10,000–39,999). Housing condi- 15 to 20) [29]. tion was classified into basic (tenement building, public The fourth questionnaire was the Children Fear Sur- permanent housing), moderate (home ownership vey Schedule Dental Subscale (CFSS-DS), which was scheme, village house, and dormitory) and good (owned used to assess child’s DFA. CFSS-DS consists of 15 items or rent private housing estates). Around 61.5% lived in on various anxiety stimuli [31]. To each item, the re- basic housing condition. The majority of mothers sponse ranges 1–5, from “not afraid at all” to “very much (74.3%) and fathers (72.8%) reported secondary school as afraid”. The total score ranges from 15 to 75. Children their highest education level. Occupation is classified Wu and Gao BMC Oral Health (2018) 18:100 Page 4 of 10 Table 1 Socio-demographic profiles of participants into managerial or professional (managers and adminis- trators, professionals, self-employed), clerical or skilled n% workers (associate professionals, clerical support Child’s demographic workers), service or labours (sales, unskilled laborers, Gender Male 188 46.7 service industry) and housewives/unemployed. Female 215 53.3 Two-thirds (64.2%) of mothers were housewives. Age (years) 9 69 17.9 Two-thirds (40.8%) of fathers were in the industry of 10–11 274 71.0 “service or labours”. 12–13 43 11.1 The majority (91.5%) of children were from nuclear families. Most (70.3%) children had siblings and more Place of birth Hong Kong 355 90.3 than half (55.9%) were the first child in the family. Other places 38 9.7 Among the three parenting styles, both parents scored Parents’ demographic the highest in authoritativeness. The means (SD) were Mother’s age (years) 34 or below 45 12.1 3.6 (0.8) and 3.6 (0.9) for mothers and for fathers 35–44 234 62.7 respectively. This was followed by “authoritarian”, for 45 or above 94 25.2 which the means (SD) were 3.1 (0.8) and 3.0 (0.9) for mothers and fathers respectively. The scores were the Father’s age (years) 34 or below 7 2.0 lowest in permissiveness, with a mean (SD) of 2.6 (0.8) 35–44 131 37.3 and 2.8 (0.9) for mothers and fathers respectively. “Au- 45 or above 213 60.7 thoritative” was identified as the dominant parenting Socio-economic status of the family style for 68.6 and 72.1% mothers and fathers respect- Family monthly income Low (<HKD10000) 71 20.4 ively; while 25.0% mothers and 18.0% fathers practiced Moderate (HKD10000–39999) 242 69.5 authoritarian parenting. Only 6.4% mothers and 9.9% fa- thers were permissive. High (≥HKD40000) 35 10.1 Housing condition Basic 236 61.5 Moderate 46 12.0 Dental fear and anxiety (DFA) of child and parents Table 2 shows children’s responses to possible fearful Good 102 26.6 events related to dental practice. Items that over 20% Mother’s Education Elementary school or below 33 8.7 children felt “very much afraid” or “pretty much afraid” Secondary school 281 74.3 were “the dentist drilling” (32.1%), “the sight of dentist Tertiary education or above 64 16.9 drilling” (24.3%), “having a stranger touch you” (23.6%), Father’s Education Elementary school or below 39 11.0 “hearing drilling sound” (22.5%) and “injection” (20.6%). Secondary school 257 72.8 As for their DFA level, 66.9% of the children were con- sidered non-fearful, 15.3% were moderate and 17.8% Tertiary education 57 16.1 c were fearful. The mean (SD) total CFSS-DS score was Mother’s Occupation Managerial or professional 25 6.4 29.1 (11.0). Clerical or skilled workers 51 13.0 The DFA level of 43.4, 42.1, 11.6 and 2.8% mothers Service or labours 64 16.4 was considered low, moderate, high and severe respect- Housewives 251 64.2 ively. As for fathers’ DFA level, 54.7, 37.0, 6.6 and 1.7% Father’s Occupation Managerial or professional 56 20.2 were considered low, moderate, high and severe respect- ively. The means (SD) total CDAS score of mothers and Clerical or skilled workers 97 35.0 fathers were 9.2 (3.0) and 8.2 (2.9) respectively. Service or labours 113 40.8 Unemployed 11 4.0 Family related factors and children’s DFA Total 405 100.0 a No significant difference was found in children’sDFA Source: Wang LD-L, Lam WWT, Fielding R. 2016. Hong Kong Chinese parental attitudes towards vaccination and associated socio-demographic disparities. among all socio-economic subgroups (all p > 0.05). Vaccine. 34:1426–1429 Table 3 shows the results of bivariate analysis between Housing condition was classified into basic (tenement building, public each family related factor and children’s DFA. Parental permanent housing), moderate (home ownership scheme, village house, and dormitory) and good (owned or rent private housing estates) DFA and parenting styles of both parents were not asso- Occupation is classified into managerial or professional (managers and ciated with children’s DFA (all p > 0.05). Children having administrators, professionals, self-employed), clerical or skilled workers (associate professionals, clerical support workers), service or labours (sales, siblings tended to report DFA, as compared with single unskilled laborers, service industry) and housewives/unemployed child (37.0% vs. 24.1%; p = 0.034). They also had a higher CFSS-DS score (29.9 vs. 27.4; p = 0.025). No significant Wu and Gao BMC Oral Health (2018) 18:100 Page 5 of 10 Table 2 Children’s dental fear and anxiety (DFA) Not afraid Very little fear Moderate sfear Pretty much afraid Very much at all afraid Events/possible triggers n (%) Dentists 187 (47.3) 147 (37.2) 27 (6.8) 12 (3.0) 22 (5.6) Doctors 276 (69.9) 83 (21.0) 16 (4.1) 9 (2.3) 11 (2.8) Injections 122 (31.0) 139 (35.3) 52 (13.2) 26 (6.6) 55 (14.0) Somebody examines your mouth 265 (67.3) 93 (23.6) 24 (6.1) 6 (1.5) 6 (1.5) Having to open your mouth 334 (84.8) 44 (11.2) 7 (1.8) 3 (0.8) 6 (1.5) Having a stranger touch you 100 (25.3) 120 (30.4) 82 (20.8) 37 (9.4) 56 (14.2) Having somebody look at you 180 (45.8) 107 (27.2) 61 (15.5) 22 (5.6) 23 (5.9) Dentist drilling 97 (24.6) 92 (23.3) 79 (20.0) 42 (10.6) 85 (21.5) Sight of dentist drilling 168 (43.0) 76 (19.4) 52 (13.3) 36 (9.2) 59 (15.1) Hearing drilling sound 155 (39.6) 92 (23.5) 56 (14.3) 30 (7.7) 58 (14.8) Putting instruments in mouth 172 (43.8) 102 (26.0) 46 (11.7) 25 (6.4) 48 (12.2) Choking 163 (42.0) 116 (29.9) 58 (14.9) 22 (5.7) 29 (7.5) Having to go to the hospital 185 (47.4) 103 (26.4) 53 (13.6) 18 (4.6) 31 (7.9) People in white uniform 302 (77.0) 56 (14.3) 15 (3.8) 8 (2.0) 11 (2.8) Having the dentist clean your teeth 271 (69.0) 77 (19.6) 19 (4.8) 11 (2.8) 15 (3.8) Mean (SD) of total CFSS-DS score 29.1 (11.0) Range of total CFSS-DS score 15.0–66.0 Possible range of the scale 15.0–75.0 Level of DFA Non-fearful Moderate fear Fearful CFSS-DS score < 32 CFSS-DS score 32–39 CFSS-DS score > 39 n (%) 245 (66.9) 56 (15.3) 65 (17.8) difference was found in DFA scores of those who were children from single-parent families had lower DFA first child in the family and others. score. Subgroup analysis showed that boys’ DFA was as- When multivariate analysis (linear regression) was sociated with “having siblings”, whereas girls’ DFA was conducted (Table 4), children from single-parent families lower when they were from “single-parent families”. were found with lower CFSS-DS score as compared with Children’s DFA was however not associated with par- children from nuclear families (β = − 9.177; p = 0.029). ents’ DFA or parental styles. When stratified analysis was carried out for boys and Invasive procedures and dental pain were often girls separately (Model 2 and Model 3), it was found that reported as the most important causes of dental anxiety (i) boys who had siblings had significantly higher DFA in [5, 14]. Similarly, teenagers participating in this study contrast to those without siblings (β = 7.130; p = 0.010); tended to relate their DFA to injection and drilling; the (ii) boys whose family had a basic housing condition re- latter also extended to stimuli (sound and sight) associ- ported significantly lower DFA as compared with those ated with drilling. It is worth noting that “having a stran- under a good housing condition (β = − 7.752; p = 0.006); ger touch you” also appeared as a major fearful situation and (iii) girls from single-parent families had lower for the respondents. Our finding is somewhat in line DFA score as compared with girls from nuclear fam- with that of a previous study, in which “having a stran- ilies (β = − 13.933; p = 0.015). ger touch you” was identified as the highest-ranked cause for dental fear, followed by “injection” and “chok- Discussion ing” [34]. Although being touched by a stranger in the This study explored the possible associations between clinical scenario may not be unexpected and stressful to children’s DFA and a variety of family related factors. adult patients, it may impose considerable stress on ado- The results showed that DFA was quite common an lescents. This highlights the importance of building rap- issue reported by around one third (33.1%) of children. port and trust with adolescent patient before starting In comparison with children from nuclear families, any dental examination and treatment. Wu and Gao BMC Oral Health (2018) 18:100 Page 6 of 10 Table 3 Family related factors and Children’s DFA No fear (CFSS-DS <32) Moderate fear (CFSS-DS 32-39) Severe fear (CFSS-DS >39) Total CFSS-DS score n (%) Mean (SD) Parental dental fear CDAS scale of mother Low anxiety 109 (69.4) 27 (17.2) 21 (13.4) 27.90 (10.02) Moderate anxiety 90 (63.8) 20 (14.2) 31 (22.0) 29.72 (11.98) High/sever anxiety 35 (66.0) 8 (15.1) 10 (18.9) 30.49 (10.62) P = 0.411 P = 0.277 CDAS scale of father Low anxiety 128 (70.3) 21 (11.5) 33 (18.1) 28.42 (11.75) Moderate anxiety 78 (62.4) 22 (17.6) 25 (20.0) 29.80 (10.63) High/sever anxiety 13 (56.5) 7 (30.4) 3 (13.0) 31.39 (11.10) P = 0.141 P = 0.111 Parenting style Mother dominant style Authoritative 167 (68.2) 33 (13.5) 45 (18.4) 28.91 (10.75) Authoritarian 58 (63.7) 18 (19.8) 15 (16.5) 29.54 (11.64) Permissive 16 (69.6) 2 (8.7) 5 (21.7) 28.87 (13.23) P = 0.593 P = 0.853 Father dominant style Authoritative 164 (66.9) 39 (15.9) 42 (17.1) 28.56 (10.63) Authoritarian 42 (64.6) 10 (15.4) 13 (20.0) 30.52 (11.74) Permissive 24 (70.6) 4 (11.8) 6 (17.6) 29.54 (13.22) P = 0.952 P = 0.531 Family characteristics Family structure Nuclear family 212 (66.3) 51 (15.9) 57 (17.8) 29.1 (11.1) Single-parent family 23 (76.7) 3 (10.0) 4 (13.3) 26.3 (9.6) p = 0.500 p = 0.167 Having siblings Yes 158 (62.9) 45 (17.9) 48 (19.1) 29.9 (11.1) No 85 (75.9) 10 (8.9) 17 (15.2) 27.4 (10.8) p = 0.034* p = 0.025* First child Yes 141 (70.5) 22 (11.0) 37 (18.5) 28.8 (11.4) No 98 (62.8) 31 (19.9) 27 (17.3) 29.4 (10.4) p = 0.065 p = 0.280 p values for categorical outcomes were obtained from the Chi-square test. p values for continuous outcomes were obtained from the non-parametric test (Mann- Whitney U test or Kruskal-Wallis test) *Significant difference It was often speculated that parental DFA and par- American study. There is a notion that older chil- enting styles are associated with children’sDFA.Such dren’s perception of dental treatment is more influ- association was supported by a studies conducted in enced by their actual dental experience such as the US [12] and was however absent in our study painful procedure and professional’s behaviors [17]. sample. It is worth noting that our study focused on Fear toward unknown appears to be predominant a slightly older age group as compared with the during early childhood, but fears are usually linked to Wu and Gao BMC Oral Health (2018) 18:100 Page 7 of 10 Table 4 Determinants of DFA in children (CFSS-DS score) Model 1 (all children) Model 2 (boys) Model 3 (girls) β (95% CI)** β (95% CI)** β (95% CI)** Age (years) Continuous −0.165 (−1.229, 0.899) 0.822 (− 1.339, 2.982) − 0.838 (− 2.146, 0.470) Gender Male Female 2.554 (−0.088, 5.197)── Place of birth Hong Kong Other places −4.036 (− 8.848,0.776) 0.839 (− 6.055, 7.733) − 6.143 (− 13.355, 1.068) Family monthly income Continuous −0.098 (−1.342, 1.146) − 1.057 (− 2.835, 0.721) 0.964 (− 0.925, 2.854) Family housing condition Good Moderate −3.373 (− 8.068, 1.322) −7.011 (− 13.943, − 0.079) −2.977(− 9.927, 3.972) Basic −3.247 (− 6.857,0.363) −7.752 (− 13.204, − 2.301)* − 2.061 (− 7.240, 3.117) ## Parental Education Continuous −2.214 (− 5.415, 0.986) −4.540 (− 9.825, 0.745) −1.907 (− 6.314, 2.500) ## # Parental Occupation Unemployed/housewives Service /labours 3.223 (−0.014, 6.460) 5.646 (1.220, 10.071)* 1.309 (− 3.608, 6.225) Clerical/skilled workers −0.434 (− 4.916, 4.048) −5.057 (− 12.018, 1.904) −0.509 (− 6.841, 5.822) Managerial/ professional 2.748 (− 6.035, 11.530) 15.713 (− 0.516, 31.942) − 4.041 (− 15.161, 7.079) Age of first dental visit 1–6 years-old 7–11 years-old −0.153 (− 3.857, 3.551) −3.001 (− 8.119, 2.117) 3.416 (− 2.348, 9.179) First visit as checkup Checkup Treatment −0.749 (− 3.844, 2.347) 1.520 (−3.098, 6.138) − 1.885 (− 6.179, 2.409) Having sibling No Yes 3.386 (−0.210, 6.982) 7.130 (1.757, 12.503)* 1.147 (− 4.228, 6.523) First child No Yes 1.038 (−2.317, 4.394) 3.159 (−2.090, 8.408) − 0.010 (− 4.761, 4.740) Family structure Nuclear family Single-parent family −9.177(− 17.418,-0.936)* − 4.564 (− 17.936, 8.808) −13.933(− 25.136,-2.731)* Mother’s dominant parenting style Authoritative Authoritarian 0.062 (−3.283, 3.407) 0.222 (−4.494, 4.938) − 0.504 (− 5.392, 4.385) Permissive 2.277 (−4.071, 8.624) 0.651 (− 10.264, 11.566) 2.921 (−5.681, 11.523) Father’s dominant parenting style Authoritative Authoritarian 0.099 (−3.662, 3.859) 0.720 (−4.730, 6.170) 0.383 (−5.239, 6.006) Permissive 1.689 (−2.723, 6.101) 4.298 (−1.834, 10.430) −1.052 (− 7.703, 5.599) Mother’s dental fear Continuous 0.209 (−0.251, 0.669) 0.388 (−0.267, 1.042) 0.044 (− 0.627, 0.716) Father’s dental fear Continuous 0.298 (−0.178, 0.774) 0.310 (−0.344, 0.965) 0.310 (− 0.407, 1.027) Constant 28.845(13.512, 44.177) 22.804(−5.129, 50.737) 37.964 (17.833,58.095) 2 2 2 R = 0.095 R = 0.224 R = 0.117 The results were obtained through multiple linear regressions using total CFSS–DS score of all children, CFSS–DS score of boys, and CFSS–DS score of girls as a dependent variable respectively. Independent variables are as above *Significant difference between/among subgroups **CI: confidence interval Reference group ## Parental education was defined as mother’s or father’s education, whichever is lower. The same conversion applied to “parental occupation” body injures including various situations encounter in not a direct factor to influence child’sDFA when the dental setting by 9 years of age [35]. A review also child reached adolescence. indicated that the relationship between parental and The finding that children in single-parent families child’ dental fear was obvious in children under reported less DFA is in congruence with a previous study 8 years old [10]. It is possible that parental DFA is [18] but contradict some others [36, 37]. In single-parent Wu and Gao BMC Oral Health (2018) 18:100 Page 8 of 10 families, children may become more independent and are only suggest associations but not causation. The sam- more likely to grow maturity and resilience [38]. Given ple of this study was drawn from children in Hong these characteristics, they may cope better with the chal- Kong. Therefore, findings of this study cannot be dir- lenges and stressful situations, such as dental visit. Also, ectly extrapolated to other populations, although some children in single-parent families may receive more atten- useful implications can be drawn especially for popu- tion from other caregivers, such as grandparents. This lations of similar cultures and social context. Although might also play a role in their growth and development. the regression models suggested the impact of familial For instance, grandfathers were identified as an important factors on children’sDFA, the R were low and the figure who can affect the emotional transmission of dental models only explained 9.5, 22.4, and 11.7% of the vari- fear among family members [13]. ance in DFA of all subjects, boys, and girls, respect- Given the gender difference in psychological ively. This supports the notion that DFA is a complex development and socialization, stratified analysis was phenomenon, in which many other factors, such as performed for boys and girls respectively. It was child’s personality traits [43], past dental experiences found that among boys, the impact of having sib- [44], other life incidents/events [45], were involved. ling(s) was evident; those with sibling(s) reported To sum up, several implications can be derived from the significantly higher DFA. There is a notion that findings of this study. The commonly neglected factors only-born children tend to internalize parents’ (e.g. “having a stranger touch you”)that trigger DFAin expectations, turn predominantly mature, have children implies that dental personnel could consider higher self-esteem, and grow adult behavior due to spending some time wherever possible to establish trust their enhanced time interacting with adults [39]. On with paediatric patients before proceeding to dental proce- the other hand, there was an alternative theory de- dures. Previous research revolved around parents’ DFA scribing personality of single-born children as more and consequently negative modeling on children. Our self-centered, demanding, shy, dependent and moody findings however suggest that the impact of family on the [40]. While the former lends support to our findings, development of children’s DFA is not as straightforward the latter points to the possibility of higher DFA in as previously speculated. In contrast to the assumption single children, which was a finding of some other held by many people, our results showed that children’s studies [21, 22]. There were also research studies DFA is not associated with parents’ DFA and parenting suggesting no difference in the personalities of single style. Instead, family structure (nuclear/single-parent child and their peers with siblings when judged by family) and presence of siblings plays a significant role parents, teachers, and themselves [41] Apart from in children’s DFA. To prevent and intercept DFA among personality traits, siblings’ past dental experience and children, it may be important to redirect the attention their positive or negative modeling might play an from parental influence to possible negative influence of important role in shaping children’s perception of siblings. Although children from nuclear family might dental care. The analysis for girls showed that living benefit from such healthy family environment in many as- in a single family indicated a lower level of DFA, as pects of their personal growth, they are more likely to compared with those in nuclear families. It is be- have DFA. Parents and clinicians are advised to be more lieved that girls are more adult-oriented [42]; there- sensitive to the signs of DFA in these children and make fore they may be more affected by parental factors necessary efforts to prepare them for dental visits. and less by their siblings. Thefindingsofthisstudy could be better interpreted by Conclusions taking into consideration the methodological strengthens Family structure (nuclear or single-parent family) and and limitations. Data were collected from a relatively large presence of siblings are significant determinants for chil- sample with diverse backgrounds. Well-established and val- dren’s DFA. Parental DFA and parenting style do not idated psychometric scales were used to measure parenting affect children’s DFA significantly. styles and the DFA of children and their parents. For determining the parenting styles, different scales are avail- able and can be completed by parents or children. Since Additional file parents may tend to give socially desirable answers and their perceptions may not truly reflect the reality, children’s Additional file 1: Scales used (PDF 265 kb) response is preferable. Although some items may seem ab- stract, reliable answers could be obtained from adolescents Abbreviations through proper wording of the questions. This study is CDAS: Corah Dental Anxiety Scale; CFSS–DS: Fear Survey Schedule-Dental cross-sectional in nature. Therefore, no temporal rela- Subscale; DFA: Dental fear and anxiety; PAQ: Parent Authority Questionnaire; tionship can be established and our findings could SPSS: Statistical Package for Social Sciences Wu and Gao BMC Oral Health (2018) 18:100 Page 9 of 10 Acknowledgements 10. Themessl-Huber M, Freeman R, Humphris G, MacGillivray S, Trezi N. The following people have contributed significantly to the subject Empirical evidence of the relationship between parental and child dental recruitment, preparation of questionnaires, data collection, and data fear: a structured review and meta-analysis. Int J Paediatr Dent. 2010;20:83–101. handling: CHU Sin Po, KWOK Hoi Ching Venus, LAI Wing Tak, LEE Hor Ching, 11. Boynes SG, Abdulwahab M, Kershner E, Mickens F, Riley A. Analysis of MOK Kar Po Carolle, NGAN Ming Chun, WONG Wing Lam, YIP Chun Kit and parental factors and parent-child communication with pediatric patients YU Chak Fai. referred for nitrous oxide administration in a rural community health center setting. Oral Biol Dent. 2014;2:10. 12. Majstorovic M, Morse DE, Do D, Lim L, Herman NG, Moursi AM. Indicators of Funding dental anxiety in children just prior to treatment. J Clin Pediatr Dent. 2014; This study was financially supported by the Faculty of Dentistry, The 39:12–7. University of Hong Kong. The funding body played no role in the design of the study and collection, analysis, and interpretation of the data and in 13. Lara A, Crego A, Romero-Maroto M. Emotional contagion of dental fear to writing the manuscript. children: the fathers' mediating role in parental transfer of fear. Int J Paediatr Dent. 2012;22:324–30. 14. Olak J, Saag M, Honkala S, Nommela R, Runnel R, Honkala E, Karjalainen S. Availability of data and materials Children's dental fear in relation to dental health and parental dental fear. The datasets used and/or analyzed during the current study are available Stomatologija. 2013;15:26–31. from the corresponding author on reasonable request. 15. Burlaka V. Externalizing behaviors of Ukrainian children: the role of parenting. Child Abuse Negl. 2016;54:23–32. Authors’ contributions 16. Baumrind D. Current patterns of parental authority. Dev Psychol. 1971;4:1–103. LW contributed to the data analysis and manuscript preparation. XG 17. Ten Berge M, Veerkamp JS, Hoogstraten J, Prins PJM. Childhood dental fear contributed to the design of the work and supervised the data collection, in relation to parental child-rearing attitudes. Psy Report. 2003;92:43–50. data analysis, manuscript preparation and critical revisions. Both authors have 18. Krikken JB, Vanwijk AJ, Tencate JM, Veerkamp JS. Child dental anxiety, read and approved the final version of the manuscript submitted for parental rearing style and dental history reported by parents. Eur J Paediatr publication. Dent. 2013;14:258–62. 19. Sulloway FJ. Birth-order, sibling competition, and human behavior. In: Ethics approval and consent to participate Holcomb HR, editor. Conceptual challenges in evolutionary psychology: The protocol of this study was reviewed by the Institutional Review Board innovative research strategies. 3rd ed. Dordrecht, the Netherlands: Kluwer (IRB) of the University of Hong Kong/Hospital Authority Hong Kong West Academic; 2001. Cluster. An ethical approval was obtained (#UW16–130). Informed written 20. Gould SJ. Dolly's fashion and louis's passion. (implications of the current consent was taken from both parents of each participating child. fascination with the genetic sciences and its use in popular culture to explain moral and behavioral phenomena: cloned sheep and behavior of Competing interests first-born judges who condemned louis xiv). Nat Hist. 1997;106:18. The authors declare that they have no competing interests. 21. Aminabadi NA, Sohrabi A, Erfanparast LK, Oskouei SG, Ajami BA. Can birth order affect temperament, anxiety and behavior in 5 to 7-year-old children in the dental setting? J Contemp Dent Pract. 2011;12:225–31. Publisher’sNote 22. Ghaderi F, Fijan S, Hamedani S. How do children behave regarding their Springer Nature remains neutral with regard to jurisdictional claims in birth order in dental setting? J dent (Shiraz,Iran). 2015;16:329–34. published maps and institutional affiliations. 23. 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Children’s dental fear and anxiety: exploring family related factors

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Dentistry; Dentistry; Oral and Maxillofacial Surgery
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Abstract

Background: Dental fear and anxiety (DFA) is a major issue affecting children’s oral health and clinical management. This study investigates the association between children’s DFA and family related factors, including parents’ DFA, parenting styles, family structure (nuclear or single-parent family), and presence of siblings. Methods: A total of 405 children (9–13 years old) and their parents were recruited from 3 elementary schools in Hong Kong. Child’s demographic and family-related information was collected through a questionnaire. Parents’ and child’s DFA were measured by using the Corah Dental Anxiety Scale (CDAS) and Children Fear Survey Schedule- Dental Subscale (CFSS–DS), respectively. Parenting styles were gauged by using the Parent Authority Questionnaire (PAQ). Results: DFA was reported by 33.1% of children. The mean (SD) CFSS-DS score was 29.1 (11.0). Children with siblings tended to report DFA (37.0% vs. 24.1%; p = 0.034) and had a higher CFSS-DS score (29.9 vs. 27.4; p =0.025) as compared with their counterpart. Children from single-parent families had lower CFSS-DS score as compared with children from nuclear families (β = − 9.177; p = 0.029). Subgroup analysis showed a higher CFSS-DS score among boys with siblings (β =7.130; p = 0.010) as compared with their counterpart; girls’ from single-parent families had a lower CFSS-DS score (β = − 13.933; p = 0.015) as compared with girls from nuclear families. Children’sDFA wasnotassociated with parents’ DFA or parenting styles (p >0.05). Conclusions: Family structure (nuclear or single-parent family) and presence of siblings are significant determinants for children’s DFA. Parental DFA and parenting style do not affect children’s DFA significantly. Keywords: Dental fear, Dental anxiety, Children, Parents, Parenting styles, Family factors Background acquisition in childhood may track into adulthood and is Dental fear and dental anxiety (DFA) refer to the strong a significant predictor for dental avoidance in adulthood negative feelings associated with dental treatment, [6, 7]. Preventing and intercepting DFA during whether or not the criteria for a diagnosis of dental pho- childhood is considered as a critical approach for im- bia are met [1]. The reported prevalence of DFA among proving people’s oral health and dental experience [5]. children and adolescents in different countries ranged It was speculated that parents’ DFA might exerts an from 5 to 33% [1–4]. Children with DFA often try all influence on their children’s DFA through modeling and means to avoid or delay dental treatment, resulting in information [8]. Many adults with DFA may verbalize deterioration of their oral health [5]. They also their fearful feelings in front of their children, creating a demonstrate poor cooperation during dental visits, negative impression on dental treatment [5]. Most which compromises the treatment outcomes, creates oc- children at early school age begin to emulate their par- cupational stress on dental staff, and causes discord be- ents who are looked upon as models [9]. They are very tween dental professionals and their parents [1]. DFA likely to internalize their parents’ values, attitudes and worldviews, which would gradually become a part of * Correspondence: gaoxl@hku.hk their own belief system [9]. There is moderate evidence Dental Public Health, Faculty of Dentistry, The University of Hong Kong, 3rd to support the relationship between parental and child Floor, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong DFA [10]. An American study reported that over 40% of Kong Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wu and Gao BMC Oral Health (2018) 18:100 Page 2 of 10 parents/guardians gave their children negative connota- factors, namely parents’ DFA, parenting styles, family tion about their previous dental visit [11]. This study structure (single-parent or nuclear family), and presence also showed a shared anxiety between parents/guardians of siblings. and their children, thus suggesting that parents played a key role in children’s anxiety and fear development. Methods In another study, parental dental anxiety was demon- Sample size calculation strated as a significant indicator for children’sdental The sample size was calculated by using G*Power anxiety (β = 0.244; p = 0.016) [12]. Despite the poten- version 3.1.9.2. Targeting a statistical power of 0.9 and a tial influence of parents, consensus is lacking regard- significant level of 0.05 and estimating 13.5% children ing whether mother or father plays a more significant have DFA [25], 373 subjects are needed to detect an role in children’s DFA. A previous study concluded effect size of 0.5. that fathers deliver major information, such as danger, to children and play a mediating role for the transfer Participant recruitment of dental fear from parents to children [13]. However, The protocol of this study was reviewed by the Institu- another study showed no significant difference be- tional Review Board (IRB) of the University of Hong tween the influence of mothers and fathers on their Kong/Hospital Authority Hong Kong West Cluster. An children’sDFA [14]. ethical approval was obtained (#UW16–130). Parenting styles provided an environmental framework A list of government-funded elementary schools was for children’s psychosocial growth and were assumed to retrieved from the official website of the Education shape children’s behaviors [15]. Baumrind identified Bureau, Hong Kong Special Administrative Region three main styles of parenting, namely authoritative, (http://www.edb.gov.hk). Among a total of 454 schools, 5 authoritarian, and permissive [16]. This classification of were randomly selected and approached. Three out of the 5 parenting styles has served as a useful tool for investigat- elementary schools participated. Child-mother-father ing the influence of parenting on various issues concern- triads were recruited. The inclusion criteria were: (i) ing child development [16]. The relationship between the school was a government-funded, co-educational parenting styles and children’s dental fear has attracted school (i.e. mixed-sex school); (ii) the child was en- some scholarly attention. A study measured parents’ rolled in Primary 4–6 of a participating school; (iii) child-rearing attitudes and found that the subscale the child was 9–13 years old; and (iv) the child and self-complaints (example item “My child’s happiness his/her both parents were literate and were able to needs a lot of sacrifice on my part”) were associated with complete questionnaires themselves. Children with se- children’s dental fear [17]. However, another study found vere systemic diseases or physical or psychological no association between parenting styles and dental anx- disabilities were excluded. All eligible children in the iety of children [18]. With limited evidence gleaned from participating schools were approached. Children with very few studies, the association between parenting informed written consent from both parents were styles and children’s DFA remains ambiguous. recruited. In addition, a family dynamics model revealed that birth order could influence one’s personality and behav- ior [19]. It has been reported that children’s birth order Questionnaires partially determines their ability to cope with stresses in Each participating family was asked to complete a set of medical situations [20]. In the dental setting, only born four questionnaires. The questionnaires were distributed children and first-born children were found to have a via class teachers and were completed by the higher clinical situational DFA and were less cooperative participants at home on a self-administered basis. Clear than others [21, 22]. A study involving children of vari- instructions were given to avoid confusion. All question- ous age showed that more children reported to have naires were completed anonymously. Each participating DFA if their siblings reported DFA [23]. However, no as- family was identified with a code and their names were sociation was found between children’s DFA and the not disclosed. The questionnaires were pretested among number of children in their families in another study 6 families with diverse background to ensure relevance [24]. The current evidence concerning how birth order and clarity. Completing the questionnaires took approxi- and presence of siblings are associated with children’s mately 20 min. DFA remains scarce and inconsistent findings have been The first questionnaire, completed by parents, reported. collected information on the child’s demographic back- In view of the currently insufficient and contradictory ground (age, gender, and birth place), family socioeco- evidence, this study aimed to investigate the association nomic status (family income, parents’ education levels, between children’s DFA and a variety of family related parents’ occupation, and housing condition), family Wu and Gao BMC Oral Health (2018) 18:100 Page 3 of 10 structure (single-parent or nuclear family), presence of with a total CFSS-DS score below 32 are considered sibling, and the birth order of the child. non-fearful; 32–39 is defined as moderate fearful; > 39 is The second questionnaire was the Parental Authority defined as fearful [31]. CFSS-DS is deemed one of the Questionnaire (PAQ); a psychometric scale that assesses most commonly used psychological scales for children. the authoritativeness, authoritarianism and permissive- A Chinese version of CFSS-DS [32] was used in this ness practiced by fathers and mothers, respectively, in study and was completed by the child him/herself. The rearing their children. This study used a short version test-retest reliability (intraclass correlation) of CFSS-DS comprising 20 items, which was adapted from the Buri’s was 0.71 and the internal consistency (Cronbach’s alpha) 30-item PAQ and showed adequate validity and internal was 0.85 [33]. The validity was good; higher mean consistency in children [26]. Test-retest reliability (the CFSS-DS scores were found in children who were de- intraclass correlation) of Buri’s PAQ were 0.77–0.92 and fined as uncooperative by using the Frankl Scale (stan- internal consistency (Cronbach alpha) were 0.74–0.87 dardized mean difference = 1.15; p < 0.01) [33]. All scales [27]. The validity was adequate; authoritarianism was in- used can be found in Additional file 1. versely related to permissiveness (mother: r = − 0.38; father: r = − 0.50; all p < 0.0005) and authoritativeness Statistical analysis (mother: r = − 0.48; father: r = − 0.52; all p < 0.0005) and The data analysis was performed by using Statistical permissiveness was not significantly related to authorita- Package for Social Sciences (SPSS) version 23.0. Partici- tiveness (mother: r = 0.07; father: r = 0.12; all p > 0.10) pants’ socio-demographic profile and family related fac- [27]. The Chinese version of PAQ was adopted [28]. tors were described. Parametric and non-parametric There were 7 items for authoritativeness, 7 for authori- tests were used for comparing means/medians, whereas tarianism, and 6 for permissiveness. Responses to each Chi-square tests were used for comparing proportions. item are made on a 5-point Likert scale, ranging from Multiple linear regression models were constructed to “strongly disagree” to “strongly agree”. The total score test the associations after controlling for possible con- for each parenting style was calculated by summing founders. The collinearity among independent variables scores of items in the corresponding parenting style. has been tested. In order to avoid possible collinearity, Among the three parenting styles (authoritative, authori- “mother’s education” and “father’s education” were con- tarian and permissive), the one with the highest mean verted to “parental education”, defined as education level score was regarded as the dominant parenting style for of mother or father, whichever is lower. The same con- that parent. The PAQ was completed by the child him/ version applied to “parental occupation”. After such con- herself, as instructed. versions, collinearity was ruled out because all the values The third questionnaire was Corah Dental Anxiety of tolerance were well above 0.2. The stratified analysis Scale (CDAS) for measuring parents’ DFA. CDAS has by gender was also carried out to test the associations in been widely used in research studies and its reliability, boys and girls, respectively. validity and usefulness have been documented [29]. The test-retest reliability (correlation coefficient) was 0.82 Results and the internal consistency (Kuder-Richardson For- Socio-demographic profile, family related factors and mula) was 0.86. The validity was moderate as shown by parenting styles the correlations between the dentists’ ratings and the pa- Among 881 eligible families approached, 405 partici- tients’ test scores. The scale was later translated into pated and returned the questionnaires. The response Chinese [30]. CDAS contains 4 items, where respon- rate was 46.0%. Most (71.0%) children were 10–11 year-- dents choose a score closest to their respective dental old, with some 9 year-olds and 12–13 year-olds (Table 1). situations. The score ranged from 1 (not anxious) to 5 There were 188 (46.7%) boys and 215 (53.3%) girls. Most (extremely anxious). The total score for 4 items ranges (90.3%) of them were born in Hong Kong. Around from 4 to 20, with a higher score indicating a higher two-thirds (62.7%) of mothers were in the age group of DFA level. The anxiety level was classified as “low” 35–44 and two-thirds (60.7%) of fathers were 45 or (scores below 9), “moderate” (scores from 9 to 12), above. Two-thirds (69.5%) of families had a moderate “high” (scores from 13 to 14), and “severe” (scores from monthly income (HKD 10,000–39,999). Housing condi- 15 to 20) [29]. tion was classified into basic (tenement building, public The fourth questionnaire was the Children Fear Sur- permanent housing), moderate (home ownership vey Schedule Dental Subscale (CFSS-DS), which was scheme, village house, and dormitory) and good (owned used to assess child’s DFA. CFSS-DS consists of 15 items or rent private housing estates). Around 61.5% lived in on various anxiety stimuli [31]. To each item, the re- basic housing condition. The majority of mothers sponse ranges 1–5, from “not afraid at all” to “very much (74.3%) and fathers (72.8%) reported secondary school as afraid”. The total score ranges from 15 to 75. Children their highest education level. Occupation is classified Wu and Gao BMC Oral Health (2018) 18:100 Page 4 of 10 Table 1 Socio-demographic profiles of participants into managerial or professional (managers and adminis- trators, professionals, self-employed), clerical or skilled n% workers (associate professionals, clerical support Child’s demographic workers), service or labours (sales, unskilled laborers, Gender Male 188 46.7 service industry) and housewives/unemployed. Female 215 53.3 Two-thirds (64.2%) of mothers were housewives. Age (years) 9 69 17.9 Two-thirds (40.8%) of fathers were in the industry of 10–11 274 71.0 “service or labours”. 12–13 43 11.1 The majority (91.5%) of children were from nuclear families. Most (70.3%) children had siblings and more Place of birth Hong Kong 355 90.3 than half (55.9%) were the first child in the family. Other places 38 9.7 Among the three parenting styles, both parents scored Parents’ demographic the highest in authoritativeness. The means (SD) were Mother’s age (years) 34 or below 45 12.1 3.6 (0.8) and 3.6 (0.9) for mothers and for fathers 35–44 234 62.7 respectively. This was followed by “authoritarian”, for 45 or above 94 25.2 which the means (SD) were 3.1 (0.8) and 3.0 (0.9) for mothers and fathers respectively. The scores were the Father’s age (years) 34 or below 7 2.0 lowest in permissiveness, with a mean (SD) of 2.6 (0.8) 35–44 131 37.3 and 2.8 (0.9) for mothers and fathers respectively. “Au- 45 or above 213 60.7 thoritative” was identified as the dominant parenting Socio-economic status of the family style for 68.6 and 72.1% mothers and fathers respect- Family monthly income Low (<HKD10000) 71 20.4 ively; while 25.0% mothers and 18.0% fathers practiced Moderate (HKD10000–39999) 242 69.5 authoritarian parenting. Only 6.4% mothers and 9.9% fa- thers were permissive. High (≥HKD40000) 35 10.1 Housing condition Basic 236 61.5 Moderate 46 12.0 Dental fear and anxiety (DFA) of child and parents Table 2 shows children’s responses to possible fearful Good 102 26.6 events related to dental practice. Items that over 20% Mother’s Education Elementary school or below 33 8.7 children felt “very much afraid” or “pretty much afraid” Secondary school 281 74.3 were “the dentist drilling” (32.1%), “the sight of dentist Tertiary education or above 64 16.9 drilling” (24.3%), “having a stranger touch you” (23.6%), Father’s Education Elementary school or below 39 11.0 “hearing drilling sound” (22.5%) and “injection” (20.6%). Secondary school 257 72.8 As for their DFA level, 66.9% of the children were con- sidered non-fearful, 15.3% were moderate and 17.8% Tertiary education 57 16.1 c were fearful. The mean (SD) total CFSS-DS score was Mother’s Occupation Managerial or professional 25 6.4 29.1 (11.0). Clerical or skilled workers 51 13.0 The DFA level of 43.4, 42.1, 11.6 and 2.8% mothers Service or labours 64 16.4 was considered low, moderate, high and severe respect- Housewives 251 64.2 ively. As for fathers’ DFA level, 54.7, 37.0, 6.6 and 1.7% Father’s Occupation Managerial or professional 56 20.2 were considered low, moderate, high and severe respect- ively. The means (SD) total CDAS score of mothers and Clerical or skilled workers 97 35.0 fathers were 9.2 (3.0) and 8.2 (2.9) respectively. Service or labours 113 40.8 Unemployed 11 4.0 Family related factors and children’s DFA Total 405 100.0 a No significant difference was found in children’sDFA Source: Wang LD-L, Lam WWT, Fielding R. 2016. Hong Kong Chinese parental attitudes towards vaccination and associated socio-demographic disparities. among all socio-economic subgroups (all p > 0.05). Vaccine. 34:1426–1429 Table 3 shows the results of bivariate analysis between Housing condition was classified into basic (tenement building, public each family related factor and children’s DFA. Parental permanent housing), moderate (home ownership scheme, village house, and dormitory) and good (owned or rent private housing estates) DFA and parenting styles of both parents were not asso- Occupation is classified into managerial or professional (managers and ciated with children’s DFA (all p > 0.05). Children having administrators, professionals, self-employed), clerical or skilled workers (associate professionals, clerical support workers), service or labours (sales, siblings tended to report DFA, as compared with single unskilled laborers, service industry) and housewives/unemployed child (37.0% vs. 24.1%; p = 0.034). They also had a higher CFSS-DS score (29.9 vs. 27.4; p = 0.025). No significant Wu and Gao BMC Oral Health (2018) 18:100 Page 5 of 10 Table 2 Children’s dental fear and anxiety (DFA) Not afraid Very little fear Moderate sfear Pretty much afraid Very much at all afraid Events/possible triggers n (%) Dentists 187 (47.3) 147 (37.2) 27 (6.8) 12 (3.0) 22 (5.6) Doctors 276 (69.9) 83 (21.0) 16 (4.1) 9 (2.3) 11 (2.8) Injections 122 (31.0) 139 (35.3) 52 (13.2) 26 (6.6) 55 (14.0) Somebody examines your mouth 265 (67.3) 93 (23.6) 24 (6.1) 6 (1.5) 6 (1.5) Having to open your mouth 334 (84.8) 44 (11.2) 7 (1.8) 3 (0.8) 6 (1.5) Having a stranger touch you 100 (25.3) 120 (30.4) 82 (20.8) 37 (9.4) 56 (14.2) Having somebody look at you 180 (45.8) 107 (27.2) 61 (15.5) 22 (5.6) 23 (5.9) Dentist drilling 97 (24.6) 92 (23.3) 79 (20.0) 42 (10.6) 85 (21.5) Sight of dentist drilling 168 (43.0) 76 (19.4) 52 (13.3) 36 (9.2) 59 (15.1) Hearing drilling sound 155 (39.6) 92 (23.5) 56 (14.3) 30 (7.7) 58 (14.8) Putting instruments in mouth 172 (43.8) 102 (26.0) 46 (11.7) 25 (6.4) 48 (12.2) Choking 163 (42.0) 116 (29.9) 58 (14.9) 22 (5.7) 29 (7.5) Having to go to the hospital 185 (47.4) 103 (26.4) 53 (13.6) 18 (4.6) 31 (7.9) People in white uniform 302 (77.0) 56 (14.3) 15 (3.8) 8 (2.0) 11 (2.8) Having the dentist clean your teeth 271 (69.0) 77 (19.6) 19 (4.8) 11 (2.8) 15 (3.8) Mean (SD) of total CFSS-DS score 29.1 (11.0) Range of total CFSS-DS score 15.0–66.0 Possible range of the scale 15.0–75.0 Level of DFA Non-fearful Moderate fear Fearful CFSS-DS score < 32 CFSS-DS score 32–39 CFSS-DS score > 39 n (%) 245 (66.9) 56 (15.3) 65 (17.8) difference was found in DFA scores of those who were children from single-parent families had lower DFA first child in the family and others. score. Subgroup analysis showed that boys’ DFA was as- When multivariate analysis (linear regression) was sociated with “having siblings”, whereas girls’ DFA was conducted (Table 4), children from single-parent families lower when they were from “single-parent families”. were found with lower CFSS-DS score as compared with Children’s DFA was however not associated with par- children from nuclear families (β = − 9.177; p = 0.029). ents’ DFA or parental styles. When stratified analysis was carried out for boys and Invasive procedures and dental pain were often girls separately (Model 2 and Model 3), it was found that reported as the most important causes of dental anxiety (i) boys who had siblings had significantly higher DFA in [5, 14]. Similarly, teenagers participating in this study contrast to those without siblings (β = 7.130; p = 0.010); tended to relate their DFA to injection and drilling; the (ii) boys whose family had a basic housing condition re- latter also extended to stimuli (sound and sight) associ- ported significantly lower DFA as compared with those ated with drilling. It is worth noting that “having a stran- under a good housing condition (β = − 7.752; p = 0.006); ger touch you” also appeared as a major fearful situation and (iii) girls from single-parent families had lower for the respondents. Our finding is somewhat in line DFA score as compared with girls from nuclear fam- with that of a previous study, in which “having a stran- ilies (β = − 13.933; p = 0.015). ger touch you” was identified as the highest-ranked cause for dental fear, followed by “injection” and “chok- Discussion ing” [34]. Although being touched by a stranger in the This study explored the possible associations between clinical scenario may not be unexpected and stressful to children’s DFA and a variety of family related factors. adult patients, it may impose considerable stress on ado- The results showed that DFA was quite common an lescents. This highlights the importance of building rap- issue reported by around one third (33.1%) of children. port and trust with adolescent patient before starting In comparison with children from nuclear families, any dental examination and treatment. Wu and Gao BMC Oral Health (2018) 18:100 Page 6 of 10 Table 3 Family related factors and Children’s DFA No fear (CFSS-DS <32) Moderate fear (CFSS-DS 32-39) Severe fear (CFSS-DS >39) Total CFSS-DS score n (%) Mean (SD) Parental dental fear CDAS scale of mother Low anxiety 109 (69.4) 27 (17.2) 21 (13.4) 27.90 (10.02) Moderate anxiety 90 (63.8) 20 (14.2) 31 (22.0) 29.72 (11.98) High/sever anxiety 35 (66.0) 8 (15.1) 10 (18.9) 30.49 (10.62) P = 0.411 P = 0.277 CDAS scale of father Low anxiety 128 (70.3) 21 (11.5) 33 (18.1) 28.42 (11.75) Moderate anxiety 78 (62.4) 22 (17.6) 25 (20.0) 29.80 (10.63) High/sever anxiety 13 (56.5) 7 (30.4) 3 (13.0) 31.39 (11.10) P = 0.141 P = 0.111 Parenting style Mother dominant style Authoritative 167 (68.2) 33 (13.5) 45 (18.4) 28.91 (10.75) Authoritarian 58 (63.7) 18 (19.8) 15 (16.5) 29.54 (11.64) Permissive 16 (69.6) 2 (8.7) 5 (21.7) 28.87 (13.23) P = 0.593 P = 0.853 Father dominant style Authoritative 164 (66.9) 39 (15.9) 42 (17.1) 28.56 (10.63) Authoritarian 42 (64.6) 10 (15.4) 13 (20.0) 30.52 (11.74) Permissive 24 (70.6) 4 (11.8) 6 (17.6) 29.54 (13.22) P = 0.952 P = 0.531 Family characteristics Family structure Nuclear family 212 (66.3) 51 (15.9) 57 (17.8) 29.1 (11.1) Single-parent family 23 (76.7) 3 (10.0) 4 (13.3) 26.3 (9.6) p = 0.500 p = 0.167 Having siblings Yes 158 (62.9) 45 (17.9) 48 (19.1) 29.9 (11.1) No 85 (75.9) 10 (8.9) 17 (15.2) 27.4 (10.8) p = 0.034* p = 0.025* First child Yes 141 (70.5) 22 (11.0) 37 (18.5) 28.8 (11.4) No 98 (62.8) 31 (19.9) 27 (17.3) 29.4 (10.4) p = 0.065 p = 0.280 p values for categorical outcomes were obtained from the Chi-square test. p values for continuous outcomes were obtained from the non-parametric test (Mann- Whitney U test or Kruskal-Wallis test) *Significant difference It was often speculated that parental DFA and par- American study. There is a notion that older chil- enting styles are associated with children’sDFA.Such dren’s perception of dental treatment is more influ- association was supported by a studies conducted in enced by their actual dental experience such as the US [12] and was however absent in our study painful procedure and professional’s behaviors [17]. sample. It is worth noting that our study focused on Fear toward unknown appears to be predominant a slightly older age group as compared with the during early childhood, but fears are usually linked to Wu and Gao BMC Oral Health (2018) 18:100 Page 7 of 10 Table 4 Determinants of DFA in children (CFSS-DS score) Model 1 (all children) Model 2 (boys) Model 3 (girls) β (95% CI)** β (95% CI)** β (95% CI)** Age (years) Continuous −0.165 (−1.229, 0.899) 0.822 (− 1.339, 2.982) − 0.838 (− 2.146, 0.470) Gender Male Female 2.554 (−0.088, 5.197)── Place of birth Hong Kong Other places −4.036 (− 8.848,0.776) 0.839 (− 6.055, 7.733) − 6.143 (− 13.355, 1.068) Family monthly income Continuous −0.098 (−1.342, 1.146) − 1.057 (− 2.835, 0.721) 0.964 (− 0.925, 2.854) Family housing condition Good Moderate −3.373 (− 8.068, 1.322) −7.011 (− 13.943, − 0.079) −2.977(− 9.927, 3.972) Basic −3.247 (− 6.857,0.363) −7.752 (− 13.204, − 2.301)* − 2.061 (− 7.240, 3.117) ## Parental Education Continuous −2.214 (− 5.415, 0.986) −4.540 (− 9.825, 0.745) −1.907 (− 6.314, 2.500) ## # Parental Occupation Unemployed/housewives Service /labours 3.223 (−0.014, 6.460) 5.646 (1.220, 10.071)* 1.309 (− 3.608, 6.225) Clerical/skilled workers −0.434 (− 4.916, 4.048) −5.057 (− 12.018, 1.904) −0.509 (− 6.841, 5.822) Managerial/ professional 2.748 (− 6.035, 11.530) 15.713 (− 0.516, 31.942) − 4.041 (− 15.161, 7.079) Age of first dental visit 1–6 years-old 7–11 years-old −0.153 (− 3.857, 3.551) −3.001 (− 8.119, 2.117) 3.416 (− 2.348, 9.179) First visit as checkup Checkup Treatment −0.749 (− 3.844, 2.347) 1.520 (−3.098, 6.138) − 1.885 (− 6.179, 2.409) Having sibling No Yes 3.386 (−0.210, 6.982) 7.130 (1.757, 12.503)* 1.147 (− 4.228, 6.523) First child No Yes 1.038 (−2.317, 4.394) 3.159 (−2.090, 8.408) − 0.010 (− 4.761, 4.740) Family structure Nuclear family Single-parent family −9.177(− 17.418,-0.936)* − 4.564 (− 17.936, 8.808) −13.933(− 25.136,-2.731)* Mother’s dominant parenting style Authoritative Authoritarian 0.062 (−3.283, 3.407) 0.222 (−4.494, 4.938) − 0.504 (− 5.392, 4.385) Permissive 2.277 (−4.071, 8.624) 0.651 (− 10.264, 11.566) 2.921 (−5.681, 11.523) Father’s dominant parenting style Authoritative Authoritarian 0.099 (−3.662, 3.859) 0.720 (−4.730, 6.170) 0.383 (−5.239, 6.006) Permissive 1.689 (−2.723, 6.101) 4.298 (−1.834, 10.430) −1.052 (− 7.703, 5.599) Mother’s dental fear Continuous 0.209 (−0.251, 0.669) 0.388 (−0.267, 1.042) 0.044 (− 0.627, 0.716) Father’s dental fear Continuous 0.298 (−0.178, 0.774) 0.310 (−0.344, 0.965) 0.310 (− 0.407, 1.027) Constant 28.845(13.512, 44.177) 22.804(−5.129, 50.737) 37.964 (17.833,58.095) 2 2 2 R = 0.095 R = 0.224 R = 0.117 The results were obtained through multiple linear regressions using total CFSS–DS score of all children, CFSS–DS score of boys, and CFSS–DS score of girls as a dependent variable respectively. Independent variables are as above *Significant difference between/among subgroups **CI: confidence interval Reference group ## Parental education was defined as mother’s or father’s education, whichever is lower. The same conversion applied to “parental occupation” body injures including various situations encounter in not a direct factor to influence child’sDFA when the dental setting by 9 years of age [35]. A review also child reached adolescence. indicated that the relationship between parental and The finding that children in single-parent families child’ dental fear was obvious in children under reported less DFA is in congruence with a previous study 8 years old [10]. It is possible that parental DFA is [18] but contradict some others [36, 37]. In single-parent Wu and Gao BMC Oral Health (2018) 18:100 Page 8 of 10 families, children may become more independent and are only suggest associations but not causation. The sam- more likely to grow maturity and resilience [38]. Given ple of this study was drawn from children in Hong these characteristics, they may cope better with the chal- Kong. Therefore, findings of this study cannot be dir- lenges and stressful situations, such as dental visit. Also, ectly extrapolated to other populations, although some children in single-parent families may receive more atten- useful implications can be drawn especially for popu- tion from other caregivers, such as grandparents. This lations of similar cultures and social context. Although might also play a role in their growth and development. the regression models suggested the impact of familial For instance, grandfathers were identified as an important factors on children’sDFA, the R were low and the figure who can affect the emotional transmission of dental models only explained 9.5, 22.4, and 11.7% of the vari- fear among family members [13]. ance in DFA of all subjects, boys, and girls, respect- Given the gender difference in psychological ively. This supports the notion that DFA is a complex development and socialization, stratified analysis was phenomenon, in which many other factors, such as performed for boys and girls respectively. It was child’s personality traits [43], past dental experiences found that among boys, the impact of having sib- [44], other life incidents/events [45], were involved. ling(s) was evident; those with sibling(s) reported To sum up, several implications can be derived from the significantly higher DFA. There is a notion that findings of this study. The commonly neglected factors only-born children tend to internalize parents’ (e.g. “having a stranger touch you”)that trigger DFAin expectations, turn predominantly mature, have children implies that dental personnel could consider higher self-esteem, and grow adult behavior due to spending some time wherever possible to establish trust their enhanced time interacting with adults [39]. On with paediatric patients before proceeding to dental proce- the other hand, there was an alternative theory de- dures. Previous research revolved around parents’ DFA scribing personality of single-born children as more and consequently negative modeling on children. Our self-centered, demanding, shy, dependent and moody findings however suggest that the impact of family on the [40]. While the former lends support to our findings, development of children’s DFA is not as straightforward the latter points to the possibility of higher DFA in as previously speculated. In contrast to the assumption single children, which was a finding of some other held by many people, our results showed that children’s studies [21, 22]. There were also research studies DFA is not associated with parents’ DFA and parenting suggesting no difference in the personalities of single style. Instead, family structure (nuclear/single-parent child and their peers with siblings when judged by family) and presence of siblings plays a significant role parents, teachers, and themselves [41] Apart from in children’s DFA. To prevent and intercept DFA among personality traits, siblings’ past dental experience and children, it may be important to redirect the attention their positive or negative modeling might play an from parental influence to possible negative influence of important role in shaping children’s perception of siblings. Although children from nuclear family might dental care. The analysis for girls showed that living benefit from such healthy family environment in many as- in a single family indicated a lower level of DFA, as pects of their personal growth, they are more likely to compared with those in nuclear families. It is be- have DFA. Parents and clinicians are advised to be more lieved that girls are more adult-oriented [42]; there- sensitive to the signs of DFA in these children and make fore they may be more affected by parental factors necessary efforts to prepare them for dental visits. and less by their siblings. Thefindingsofthisstudy could be better interpreted by Conclusions taking into consideration the methodological strengthens Family structure (nuclear or single-parent family) and and limitations. Data were collected from a relatively large presence of siblings are significant determinants for chil- sample with diverse backgrounds. Well-established and val- dren’s DFA. Parental DFA and parenting style do not idated psychometric scales were used to measure parenting affect children’s DFA significantly. styles and the DFA of children and their parents. For determining the parenting styles, different scales are avail- able and can be completed by parents or children. Since Additional file parents may tend to give socially desirable answers and their perceptions may not truly reflect the reality, children’s Additional file 1: Scales used (PDF 265 kb) response is preferable. Although some items may seem ab- stract, reliable answers could be obtained from adolescents Abbreviations through proper wording of the questions. This study is CDAS: Corah Dental Anxiety Scale; CFSS–DS: Fear Survey Schedule-Dental cross-sectional in nature. Therefore, no temporal rela- Subscale; DFA: Dental fear and anxiety; PAQ: Parent Authority Questionnaire; tionship can be established and our findings could SPSS: Statistical Package for Social Sciences Wu and Gao BMC Oral Health (2018) 18:100 Page 9 of 10 Acknowledgements 10. Themessl-Huber M, Freeman R, Humphris G, MacGillivray S, Trezi N. The following people have contributed significantly to the subject Empirical evidence of the relationship between parental and child dental recruitment, preparation of questionnaires, data collection, and data fear: a structured review and meta-analysis. Int J Paediatr Dent. 2010;20:83–101. handling: CHU Sin Po, KWOK Hoi Ching Venus, LAI Wing Tak, LEE Hor Ching, 11. Boynes SG, Abdulwahab M, Kershner E, Mickens F, Riley A. Analysis of MOK Kar Po Carolle, NGAN Ming Chun, WONG Wing Lam, YIP Chun Kit and parental factors and parent-child communication with pediatric patients YU Chak Fai. referred for nitrous oxide administration in a rural community health center setting. Oral Biol Dent. 2014;2:10. 12. Majstorovic M, Morse DE, Do D, Lim L, Herman NG, Moursi AM. Indicators of Funding dental anxiety in children just prior to treatment. J Clin Pediatr Dent. 2014; This study was financially supported by the Faculty of Dentistry, The 39:12–7. University of Hong Kong. The funding body played no role in the design of the study and collection, analysis, and interpretation of the data and in 13. Lara A, Crego A, Romero-Maroto M. Emotional contagion of dental fear to writing the manuscript. children: the fathers' mediating role in parental transfer of fear. Int J Paediatr Dent. 2012;22:324–30. 14. Olak J, Saag M, Honkala S, Nommela R, Runnel R, Honkala E, Karjalainen S. Availability of data and materials Children's dental fear in relation to dental health and parental dental fear. The datasets used and/or analyzed during the current study are available Stomatologija. 2013;15:26–31. from the corresponding author on reasonable request. 15. Burlaka V. Externalizing behaviors of Ukrainian children: the role of parenting. Child Abuse Negl. 2016;54:23–32. Authors’ contributions 16. Baumrind D. Current patterns of parental authority. Dev Psychol. 1971;4:1–103. LW contributed to the data analysis and manuscript preparation. XG 17. Ten Berge M, Veerkamp JS, Hoogstraten J, Prins PJM. Childhood dental fear contributed to the design of the work and supervised the data collection, in relation to parental child-rearing attitudes. Psy Report. 2003;92:43–50. data analysis, manuscript preparation and critical revisions. Both authors have 18. Krikken JB, Vanwijk AJ, Tencate JM, Veerkamp JS. Child dental anxiety, read and approved the final version of the manuscript submitted for parental rearing style and dental history reported by parents. Eur J Paediatr publication. Dent. 2013;14:258–62. 19. Sulloway FJ. Birth-order, sibling competition, and human behavior. In: Ethics approval and consent to participate Holcomb HR, editor. Conceptual challenges in evolutionary psychology: The protocol of this study was reviewed by the Institutional Review Board innovative research strategies. 3rd ed. Dordrecht, the Netherlands: Kluwer (IRB) of the University of Hong Kong/Hospital Authority Hong Kong West Academic; 2001. Cluster. An ethical approval was obtained (#UW16–130). Informed written 20. Gould SJ. Dolly's fashion and louis's passion. (implications of the current consent was taken from both parents of each participating child. fascination with the genetic sciences and its use in popular culture to explain moral and behavioral phenomena: cloned sheep and behavior of Competing interests first-born judges who condemned louis xiv). Nat Hist. 1997;106:18. The authors declare that they have no competing interests. 21. Aminabadi NA, Sohrabi A, Erfanparast LK, Oskouei SG, Ajami BA. Can birth order affect temperament, anxiety and behavior in 5 to 7-year-old children in the dental setting? J Contemp Dent Pract. 2011;12:225–31. Publisher’sNote 22. Ghaderi F, Fijan S, Hamedani S. How do children behave regarding their Springer Nature remains neutral with regard to jurisdictional claims in birth order in dental setting? J dent (Shiraz,Iran). 2015;16:329–34. published maps and institutional affiliations. 23. 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BMC Oral HealthSpringer Journals

Published: Jun 4, 2018

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