The use of personality measurements as a determinant of patient cooperation in an orthodontic practice

The use of personality measurements as a determinant of patient cooperation in an orthodontic practice THOMAS

KENNETH

EDWARD

W.

St. Louis,

ALLAN,

HODGSON,

PH.D.,* D.D.S.,

and

M.S.D.

MO.

THE cooperation of the patient during orthodontic treatment is one of the most important factors in obtaining a successful end result. The logic of this assertion is convincingly presented in the writings of both Jarabakll and Tweed.21 Orthodontic appliances alone are limited in what they can do. If the patient does not cooperate in wearing elastics and/or headgear, occlusal discrepancies will not be corrected. If the patient does not cooperate in keeping the appliances and his teeth clean, the end result of the orthodontic treatment may be satisfactory but the hard and soft tissues of the mouth may be damaged. If the patient does not wear retainers as directed, some of the results of orthodontic treatment will probably be lost. This study was designed to predict, by means of standardized measurements of personality, patient cooperation in a dental practice limited to orthodontics. Considerable research has been devoted to the dentist-patient relationship in the pedodontic practice, but relatively little research has been devoted exclusively to adolescents, particularly in an orthodontic practice.17 An examination of the literature shows a paucity of any type of psychological testing of the orthodontic patient. In the 1940’s, with the exception of researchers like Coriat? who published articles on the fear and anxiety associated with dental visits, behaviorists evidenced little interest in the area of dentistry and, more specifically, orthodontics. In spite of increasing interest in psychological assessment, the passage of time has failed to produce much research in this area as it relates to dental practice. In the past decade, certain dental schools have increasingly felt the need to communicate the importance of psychological knowledge to their gradu*Associate

Director

of the

Counseling

Service,

Washington

University.

433

aIltl in at IVilSt tW0 iTlStiltl(W Il;lV(~ C~VOlVcYl il SJWC~iiII 1t7lining pl’Ogl’;lI’ll inc*orJ)orating psychological tlisciplinc~s. Both the 17nivr~rsit>. of J’ittsJ)utSgh ~II~Jtltc TTnirersity of Houston have initiated such a c~urric~ululu. \\‘h(lt 1~12t IW J)(‘haviot*ilJ scientist,s will follow suit it1ic1 ~wc01nc involved in t h(l J+vc’liologi~al ~~I~~hlcitis peculiar to the practice of dentistry rctnaills to be seen. The present stntly has ~volvc~l as a result of t h(l observation that ;I few patic& were extremely cooperative in c’vcr,v facet of treatment, a great man) others were cooperut,ive some of the time or perhaps (‘ven most ot’ the timr, while a small number were constantly hostile to the entirc~ orthodontic program. It was hypothesized that it might be possible to make a. ra,piti assessment (if the personality of the incoming orthodontic patient in a way that would bc meaningfully related to his subsequent behavior in trcatmcnt. Some orthodontists make education of parent ad patient (in the form of slides, models, reading materials, oral ant1 writt,en instructions, etc. ) a vital part of their beginning course of treatment in the hope t,hat the young patient will be more cooperative. When this program has failetl to produce the desired results, it is logical to look for factors tllat might bc determining or causing the patient’s attitudes. It is hoped that t,hc present stud,v can contribute* toward t,Jle achievement of this goal. iIt(S

REVIEW

OF

THE

LITERATURE

Of the studies dealing with psychological aspects of the dental experience, the majority concern themselves with the manifestation of fea.r and psychic trauma. Research by Kominek and Srp”’ I9 indicated the high level of the child’s fear in experimental dental situations, as evidenced by pulse, respiration, blood pressure, etc. Fisher,‘. 8 Laufer and colleagues,16 and Kominek and Rozkovcova’5 discussed the use of explanation a.nd suggestion as effective tools in combating this apprehension prior to and during dental treatment. Klein’:’ considered the emotional attitudes of children of varying age groups prior to an initial dental visit. She found that children 8 pears of age and older fell into two definite groups-those who showed a cooperative approach to the dentist and those in whom definite emotional upsets were apparent. Narrowing the research arca to orthodontics and/or the factor of cooperation, three studies are of interest. Autlo’ used the galvanic skin reflex method to determine response to stimuli in the treatment situation. Hc found that t,he older the orthodontic patient, the lesser the amount of his reflex or reaction; a greater amount of reaction was with respect to all orthodontic treatment, observed in boy patients than in girl patients. Crowley and associates,5 in their study of forty patients, used a battery of five psychological tests and correlated the results with the findings of four psychologists who rated the patients in treatment. These findings supported their h?pothcsis that clental cooperation is relatetl to psychological factors in the patiwt’s personality. The use of a questionnaire which provided information concerning a child’s conduct at school was utilized by Herren and co-workers’” to determine such personality factors as sincerity, dependability, temperament, carefulness, com-

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54 6

Perso&ity

measurements

and

patient

cooperation

435

pliance, etc. Predicting the degree of the child’s cooperation in the course of orthodontic treatment, these forecasts from the questionnaire were correlated with the actual behavior of sixty-six children during treatment. In forty-nine cases not a single failure was attributed to lack of patient cooperation when trea.tment was correlated with the psychologist’s recommendations. Poor results were obtained in three cases in which the appliances that. were used demanded greater cooperation than had been previously predicted would occur. Results were inconclusive in the cases of the remaining fourteen subjects. Story2” recently published an excellent summary of the role of the orthodontist with regard to the patient and the patient’s family and the many psychological implications of orthodontic treatment in children. The work of Baldwin and Barnes,2, 3 who are in the process of examining psychosocial factors motivating orthodontic treatment, has shed light on the importance of the role of the mother. Specifically, their data. suggest that (I) the mother is usually the mobilizing, deciding, and determining member of the family in terms of the decision for trea.tment and (2) the mother may bring the child in for orthodontic treatment in an attempt to resolve her own problems. Little has been done in this particular aspect of dental research. A third finding of Baldwin and Barnes2 indicates that orthodontic treatment may be seen as a badge of social belonging and acceptance. Personality characteristics and the attitudes of the mother appear to be related to the patient’s behavior in orthodontic treatment, but this observation is ba,sed on incomplete research findings. METHODOLOGY

We decided to explore parental attitudes toward child rearing after observing that a.dditional charges to the parents of uncooperative patients often produced a marked increase in patient cooperation. At the same time, these subjects were adolescents who, to a. certain degree, were pulling away from parental influence, and it was thought that some dimension of the patient’s self-concept and personality dynamics might be of value. Thus, the parental climate in the home and the self-concept of the adolescent were the two a.rea.s of interest to be considered in terms of their relationship to the degree of cooperation in orthodontic treatment. A group of thirty patients (thirteen boys and seventeen girls), ranging in age from 12 to 18 years, was selected. Each patient had been under treatment for a minimum of one year, and most of them were from middle-class suburban backgrounds in the St. Louis, Missouri, area.. For the criterion in the study, each subject was assigned a numerical rating, according to his degree of cooperation, by the orthodontist. These ratings ranged from 1 (very poor) to 9 (very good). The distribution of assigned ratings approximated a normal distribution; one patient was rated very poor (l), four were rated as poor (3), ten were average (5), four were good (7), and one patient was rated very good (9). Two instruments were selected for use as personality measures. One was the Maryland Parent Attitude Survey (MPAS) designed by Donald Pumroy**

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fortrc~d-rcsponso instrument which :r.t,t(‘III [)ls to cwrlt ~01 t 11~3sovial tl~~sit*irhiiily of t,he choices and >-et, intlicat,c tlrc ~GIWIII;I~ oric~nt.a,tion in foul* clirc~c*f ions : tliwiplinarian, the I) scale; indulgent,, t hc I sc~alc;protc&vcb, 1 he I’ wit Iv; it tltl lT,jWting, the R scale. Studies by I’um~~)y indicate that the rrliabilit?- 0E the t’011r scales varies from .62 to .8-l which is similar t,o other instruments of this nature. Consistent, wit,h t,he findings of the stucly by Baldwin and Barnes, only the mothers of the subjects were asked to complet,e this survey. Each mother reud pairs of it,ems and decided which of the t,wo most represented her attitude toward child rearing. The test was t.hen scored by determining t,he number of items in each of the four categories t.hat were chosen. The Adjective Check List (ACL), designed by Harrison Uough,” is a rtasearch instrument used primarily for self-evaluation. It consists of a list of 300 adjectives commonly used to describe a person’s at,tributes and is based on Murray’s need-trait system. Subjects are asked to check the words that they feel describe them. The ACL may be completed in 10 or 15 minutes, even by unsophisticated subjects, arouses little resistance or anxiety, and yields a great deal of potential information. Righteen scales comprise the ACL and, when scored, indicate the individual’s self-control, self-confidence, and personal adjust,ment, along with fifteen nerds (achievement, dominance, endurance, order, intraception, nurturancc, affiliation, heterosexuality, exhibition, autonomy, aggression, change, surcorance, abasement, and deference). When testing was completed, we had. for ea.ch of our thirty patients, thirtyone observat,ions or variables: age, sex, the four variables from the Naryland Parent Attitude Survey, the twent,y-four variables from the Adjective Cheek List, and the variable of the criterion rating from the orthodontist. FINDISGS

Product moment correlations’” between the criterion and each of the independent variables were completed and are presented in Table I. Age was significantly related to the criterion at the .Ol level and, as such, was the best single predictor of patient cooperation. Since the correlation was a negative one, this would indicate that younger paGents tend to be more cooperative. The individual scales on both the Maryland Parent Attitude Survey and t,he Adjective Check List were not significantly related to the criterion. In order to see which variables in combination with each other might prove to be the best predictors of future behavior, eight predi&ors having the highest correlations with the criterion were chosen for inclusion in a stepwise regression analysis. Stepwise regression is the computat,ion of a sequence of multiple linear regression equations in which the variable in each equation that makes the least contribution to the reduction of the error variance is omitted in the succeeding linear equation. In simpler terms, the variables are dropped sequentially on the basis of the relative size of their unique contributions to the prediction. Those variables making the largest unique contribution are retained the longest,.

Volume Number

54 6

Personality

Table I. Product

measurements

moment correlations

Variable

I

sex Age

between criterion

Correlation

.oo -51”

The MPAS Disciplinarian Indulgent Protective Rejecting The ACL Total number of adjectives checked Defensiveness Favorable adjectives Unfavorable adjectives Self -confidence Lability Personal adjustment Counseling readiness *Significant

at the

and patient

-.12 -.Ol .09 $09

.33 .17 -.oo .07 .03 -.21 .Ol -.19

I

cooperation

and predictor

Variable

I

ACL needs Achievement Dominance Endurance Order Intraception Nurturance Affiliation Heterosexuality Exhibition Autonomy Aggression Change Succorance Abasement Deference

4 37

variables Correlation .21 .22 .25 .07 .09 .I3 .07 -.09 -.08 -.33 -.04 -.17 .25 .04 .12

.Ol level.

Table II. Stepwise regressioqt apdysis No.

of in

predictors equation 8 7 6 5 4 3 2 1

Variable

to be &minded

Succoranee (omitted first) Endurance (omitted second) Lability Achievement Autonomy Dominance Total number of adjectives checked Age

Ydtiple correlation coefficient

Level of significance

.805 .786 .753 .742 .677 .647 598

.Ol .Ol .Ol .OOl .Ol .Ol .Ol

.513

.Ol

The following eight variables were selected for this stepwise regression analysis : Succorance-need to solicit sympathy, affection, or emotional support from others Endurance-need to persist in any task undertaken Lability-based on characteristics such as spontaneity, flexibility, need for change, rejection of convention, and assertive individuality Achievement-need to strive to be outstanding in pursuits of socially recognized significance Autonomy-need to act independently of others or of social values and expectations

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h influential ilIlt controlling in intlivitloirl t’cl;lt itrnsliil)s Tot,al number of items c.l~clcliccI---sc~l-t’-c~s~~l;~n;~t-o~~Xge-self-cxplanator? The results of this analysis (Table II) indicate that the best combination of predictors includes age, total number of adjectives chcckctl, dominancc~, autonomy, and achievement. The multiple correlation for this equation was computed as being .71 anti was significant ilt the .OOl lc\,cl. DISCUSSION

Some comment is necessary concerning the fact that age was t,hr only significantly related variable. Because of the limited age range of the subjects (12 to 18 years) and the limited number of ca.tegories in the ratings of cooperation, it is very possible that the relationship discovered is s0mewha.t exaggerated by the use of product moment correlation. It is important that this finding be interpreted cautiously. A word should be said about a, weakness of the criterion. In spite of t.he high level of significance of the multiple predict,ors, conclusions must be tentative because of the problem presented by the fact that one person rated patient cooperation, which opens the question of the reliability of the criterion. P’or this reason, a modified replication is recommended, preferably with a design employing multiple criterion ratings. The fact that the biserial correlation between sex and the criterion was .OO suggests that patient reflex, as defined by Audo,’ is not directly related to patient cooperation, since younger rather than older patients were more cooperative and there was no difference in cooperat,ion on the basis of sex. Since none of the MPAS scales were significantly rclateti to t,he criterion, a possible conclusion might, he that this instrument, is not, getting at the same attitudes of the mother as those presented in the” studies by Baldwin and Barnes.“, ‘j Croxton” concluded that the primary factor in management problems with respect to children in dental situations may be the overpermissivenm of the parent. The MPAS did not tend to support this conclusion, but the lack of statistical significance in the present study would tend to indicate that. the selfconcept of the child himself is t,he determinant in cooperation in orthodontic treatment. At first glance, it might appear that a high need for dominance would be contraindicative of cooperation. An alternat,ive explanation might be that a forceful, strong-willed person might more easily pursue a course of action that is unsupported by the perceived reactions of peers and significant others. The preliminary findings reported by Baldwin and Barnes2 concerning orthodontic treatment as a badge of social acceptance and belonging would tend to support this explanation. Two scales of the ACL just missed being significant at the .05 level. These were (1) total number of adjectives checked and (2) autonomy. Referring to the description of these scales in the ACL manual, we get the picture of a conservative, helpful person who hesitates to t,ake t,he initiative, preferring to

Volume Number

54 6

Personality

measurements

and patient

cooperatio?L

439

wait and follow the dictates of others. According to information evolving from this finding and the results of the multiple regression analysis, the most cooperative patient is usually 14 years of age or younger, enthusiastic, outgoing, energetic, wholesome, self-controlled, responsible, trusting, determined to do well, hard-working, forthright, and obliging. The patient most likely to be termed uncooperative is more than 14 years of age, of superior intelligence, hard-headed, independent, aloof, often nervous, temperamental, impatient, individualistic, easy-going, self-sufficient, intolerant of prolonged effort or attention, and tends to disregard the wishes of others when his own desires are involved. These findings are largely in agreement with those reported by Herron and colleagues10 It would appear that it may be possible to predict the amount of difficulty that the orthodontist is likely to encounter in dealing with uncooperative patients. (The Adjective Check List could be administered to the patient on his initial visit to the orthodontist’s office. Copies of the ACL a,nd the manual may be obtained from Consulting Psychologists Press, 577 College Ave., Palo Alto, Calif.) Knowing that a patient is more likely to react in a certain way during treatment, the orthodontist could experiment with a variety of strategies to elicit the desired level of cooperation.

REFERENCES

Psychological Responses of Patients in Orthodontic Treatment, J. Nihon 1. Audo, Yoshio: Univ. School Dent. 3: 134-139, 1961. Psychosocial Factors Motivating Orthodontic Trext2. Baldwin, D. C., and Barnes, M. L.: merit, Preprinted Abstracts, I.A.D.R. 43: 461, 1965. 3. Baldwin, D. C., and Barnes, M. L.: Patterns of Motivation in F’amilies Seeking Orthodontic Treatment, Preprinted Abstracts, I.A.D.R. 44: No. 412, 1966. 4. Coriat, S. H.: Dental Anxiety: Fear of Going to the Dentist, Psychoanalyt. Rev. 33: 365-367, 1946. 5. Crowley, Robert E., Klebanoff, Seymour G., Singer, Jerome L., and Napoli, Peter J.: R,elationship Between Personality Factors and Cooperation in Dental Treatment, J. D. Res. 35: 157-165, 1956. 6. Croxton, William: Child Behavior and the Dental Experience, J. Dent. Children 34: 212217, 1967. 7. Fisher, C. G.: Theoretical Aspects of Fear, J. Dent. Children 22: 38-40, 1951. 8. Fisher, C. G.: Management of Fear in the Child Patio&, J. Am. Dent. A. 57: 792.795, 1958. 9. Gough, Harrison: The Adjective Check List Manual, Palo Alto, Calif., 1965, Consulting Psychologist5 Press. 10. Herren, P., Baumann-Rufer, H., Demisch, A., and Berg, P.: The Teacher’s Questionary -An Instrument for the Evaluation of Psychological Factors in Orthodontic Diagnosis, Rep. European Orthodont. Sot. 41: 247-266, 1965. of an Orthodontic Practice, St. Louis, 1965, The C. V. 11. Jarabak, J. R.: Management Mosby Company, p. 150. 12. Johnson, P. O., and Jackson, R. W.: Modern Statistical Methods: Descript,ive and Inductive, Chicago, 1959, Rand-McNally & Company, p. 371. 13. Klein, Hortense: Psychological Effects of Dental Treatment on Children of Different Ages, J. Dent. Children 34: 30-35, 1967. 14. Kominek, Jaroslav, and Srp, Ladislav: Fear of Dental Treatment in Children, Deutsche Zahn. Ztschr. 14: 1616-1620, 1959.

Trwtnwtmt, Jaruslav, awl li~h\.~:w:i, 3.1.: I’syc~l~nlo~y 01 ~.‘l~il~lr~.w’r Ihrt:rl I). J. 16: l-z!), l!ttiti. Laufcr, Dov, Rowuzwig, Kurt -I., awl (hptwli, .Qhrcy : I~ls~~li~~i:ct.io~~ iIS iL kIVRIIR Ul Reducing Fear of Ihntul l’rocc~lurw in Chil~lwt+ All'llIl ol,lc~g;llI 57: 130. IX. lfm. Masslcr, Maury: I’sycl~ology in Ibulistry for Cliildrw, rcl~rirbl. from I). (:liu. 9orth hmcricit, pp. 623-635, Novcmlwr, I!iti?. Yumroy, Donald: Blarylrnd hrcnt .\t.lituh Survey, t.!ollcgc I’wk, WI., 196?, Uuivcrsity of Marylaud. Srp, Ldislav, rud Kominck, Jarosluv: The: Rcuction of Cl&Iron to Ihntal Twtitmeut : An Espcrimental Study, Odont. Revy. 14: 178-156, 1963. Story, R. Ian: Psychological Issues in Orthodoutic Yracticc, AM. J. OITIIODONTWS 52: 584-597, 1966. Tweed, C. II.: Clinical Ortllodont.ica, St. Louis, 1966, The C. V. Xfosby Cnmpany, vol. II, pp. 610-614.

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