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Dentists’ Responses to Fear- and Nonfear-Related Behaviors in Children
A R T IC L E S
child appears to result in more fearrelated behaviors. This study has begun to specify be havioral interactions during routine treatm ent of young children. A d d i tional studies of other populations of children, such as school-age children, are needed. Moreover, the m ethodol ogy used in this study has the potential to assess the effects of not only behav iors, but also pharm acological m an agem ent of patients. W hat is learned from these studies may be of consider able benefit to both providers and den tal students. CT'aT',
This study was funded by grant no. 1 RO 1 DE 04770-01 from the N ational Institute for Dental Research. 1. Forgione, A.G., and Clark, R.E. Com ments on an em pirical study of the cause of dental fears. J Dent Res 53:496, 1974. 2. Shoben, E.M., and Borland, L. An em pirical study of the etiology of dental fears. J Clin Psychol 10:17-174, 1954.
3. Lautch, H. Dental phobia. Br J Psychiatry 119:151-158, 1971. 4. Kleinknecht, R.A.; Klepac, R.K., and A lexan der, L.D. O rigins and characteristics of fear of dentistry. JADA 86:842-848, 1973. 5. B ernstein, D.A.; K leinknecht, R.A.; and Alexander, L.D.Antecedents of dental fear.J Pub lic Health Dent 39(2):113-124, 1979. 6. W einstein, P. Identifying patterns of behav ior during treatm ent of children. In Ingersoll, B., and M cKutcheon, W. eds. Proceedings of the Sec ond N ational Conference on Behavioral Dentistry: Clinical Research in Behavioral Dentistry, Mor gantow n, WVa Univ of West Virginia Press, 1980. 7. Getz, T.; W einstein, P.; and Domoto, P. The effect of structural variables on child behavior in the operatory. Pediatr Dent, to be published. 8. Domoto, P.K.; W einstein, P.; and Getz, T. A pilot study using remote broadcasting equipm ent to provide instruction in pedodontics.J Dent Educ 4 3 (llptl):599-601, 1979. 9. W urster, C.A.; W einstein, P.; and Cohen, A.J. Com m unication patterns in pedodontics. Percept Mot Skills 48(1):159-166, 1979. 10. Glennon, B., and Weisz, J.R. An observa tional approach to the assessm ent of anxiety in children. J Consult Clin Psychol 46:1247-1257, 1978. 11. Sackett, G.P. M easurem ent in observational research. In Sackett, G.P., ed. Observing behavior, vol II. Baltimore, Md, University Park Press, 1978.
12. Sackett, G.P.; Stephenson, E.; and Ruppenthel, G.C. Digital data acquisition system s for ob serving behavior in laboratory and field settings. Behav Res M ethods and Instrum entation 5:344348, 1979. 13. Sackett, G.P., and others. A fortran program for lag sequential analysis of contingency and cyclicity in behavioral interaction data. Behav Res M ethods and Instrum entation, 11:366-378, 1979. 14. Howitt, J.W., and Strieker, G. Child patient responses to various dental procedures. JADA 70:70-74, 1965. 15. Langer, E.J.; Janis, I.L.; and Wolfer, J.A.Re duction of psychological stress in surgical pa tients. J Exper Soc Psychol 11:155-165, 1975. 16. Johnson, J.E.Effects of accurate expectations about sensations on the sensory and d istress com ponents of pain. J Pers Soc Psychol 27:261275, 1973. 17. Averell, J.R.Personal control over aversive stim uli and its relationship to stress. Psychol Bull 80:286-303, 1973. 18. Maccoby, E.E. Social developm ent. New York, Harcourt, Brace, Jovanovich, Inc, 1980. 19. Bernstein, L.; Bernstein, R.S.; and Dana, R.H. Interview ing: a guide for health profes sionals. New York, A ppleton-C entury-C rofts, 1974. 20. Rogers, C.R. On becoming a person. Boston, Houghton Mifflin, 1961.
Dentists’ responses to fear- and nonfear-related behaviors in children P. T. P. P.
Weinstein, PhD Getz, MS Ratener, M S Domoto, DDS, M PH
D entists m a y respond differen tly to fear- an d nonfear-related behaviors in children, an d those responses m ay influence the ch ildren’s further behavior. This study exam ines that interaction.
r
h ild re n ’s behavior in the opera tory has alw ays been of concern in dentistry. Children m ust cooperate or m ust at least passively accept treat m ent so that the dentist can com plete technical procedures. M elam ed and associates1 found that the level of fear 38 ■ JADA, Vol. 104, January 1982
experienced by the child was posi tively related to the degree of d isru p tive behavior displayed during a re storative appointm ent. Moreover, re search2'4 suggests that traum atic den tal experiences lead to the develop m ent of fear, providing support for the
supposition that the process of provid ing care is at least as im portant as the treatm ent outcome. Most research on the m anagem ent of children has been based on the tacit assum ption that the child is the prob lem and that it is his or her behavior that m ust be altered. This assum ption has led to studies designed to assess the effect of interventions to m odify the c h ild ’s behavior. Few studies have hypothesized that m anagem ent prob lems may have an iatrogenic com po n e n t, and few have a tte m p te d to exam ine how the dentist’s behaviors influence treatm ent outcome.
ARTICLES
Dentists most frequently respond to the child’s fear-related behavior with those behaviors that are counterproductive and ineffective in reducing fear: rules, coercion, coaxing, reassurances, putdowns.
A pilot study by Wurster and as sociates5 examined communication patterns during pedodontic appoint ments in a dental school setting. Six teen dental students were videotaped during a restorative appointment with a child. Markov analysis techniques were u sed to ca lcu la te the prob abilities for the occurrence of specific behaviors by the child after certain be haviors by the dentist. The prob abilities for the occurrence of specific dentist behaviors after certain child behaviors were also calculated so that the pattern of behavioral interactions would be clearer. Their results suggest that child behavior is systematically related to the communication style of the practitioner, and that the behavior of the dentist is influenced by the child’s behavior. A more thorough understanding of dentist-child interactional patterns is necessary. In a field study of private p ra ctitio n ers, W e in ste in and a s sociates6 found that the incidence of fear -and distress-related behaviors by the child varied significantly after dif ferent behaviors by the dentist. This paper describes the probabilities for the occurrence of specific dentist be haviors after fear-related and nonfearrelated child behaviors.
Method The m ethods used in this study are the same as those described in the preced ing paper. In this study, the conditional prob abilities for specific dentist behaviors in each of the four dimensions follow ing fear- and nonfear-related child be haviors were compared. The signifi cance of the differences between den tist’s responses after the child’s fear and nonfear behaviors was determined by transforming the data into 2 scores and determining the probability that the differences were due to chance. Seventy-two videotapes have been analyzed, representing two sequential appointments for 36 children. Detailed
data analysis and results are available from the authors.
Results The dentists’ responses in the guid ance dim en sio n , im m ediately after fear-related behaviors by the ch ild (first lag), were less likely to be direc tion and reinforcement; whereas after nonfear-related behaviors, the dentist was more likely to use direction, and reinforcement. The difference in the d e n tis ts ’ re sp o n ses after fear- and nonfear-related behaviors is statisti cally significant. The probability that the dentist w ill use rules, coercion, and coaxing was g re a te r im m e d ia te ly after a c h ild showed fear-related behaviors and de creased after nonfear-related behav iors. The difference in the probability that the dentist w ill use rules and coax ing is significant. In the second lag after fear-related behaviors, the probability for the den tists’s use of reinforcement, rules, and coercion was sim ilar to that of the first lag. However, the only significant dif fe re n c e b e tw e e n th e d e n tis t’s re sponses after fear- and nonfear-related behaviors occurred for reinforcement; again, the dentist was more likely to use reinforcem ent after nonfear behav iors th an after fear behaviors. The probability that the dentist w ould use explanations, a frequent dentist behav ior, and rhetorical questions rem ained unchanged after the c h ild ’s fear- and n o n fear-related beh av io rs for both lags. For the first lag in the em pathy di mension, the conditional probability
that dentists w ould use reassurance, ignoring I denying, or putdow ns in creased significantly after the ch ild ’s fear-related behaviors; w hereas the pro b ab ility th a t the d en tist w ould question for feeling decreased. Fol lowing the ch ild ’s nonfear-related be haviors, questioning for feelings in creased, w hile ignoring I denying de creased. Differences betw een the den tist’s responses to fear and nonfear be haviors are statistically significant for all dentist behaviors except reassur ance. At lag 2, the probabilities for questioning for feelings, reassurance, ignoring I denying, and putdow ns in crease following fear-related behav iors by the child. Following nonfearrelate d beh av io rs, th e co n d itio n a l probabilities for all dentist behaviors did not vary from the unconditional probabilities. Differences betw een the dentist’s responses to fear and nonfear behaviors at lag 2 are significant for reassurance, ignoring I denying, and putdow ns. In the first lag of the verbalization dim ension, im m ediately following the child’s fear-related behaviors, the den tist’s dental and nondental verbaliza tion to the assistant decreased signifi cantly, w hile dental and nondental verbalizations to the child increased. Follow ing nonfear-related behaviors by the child, the dentist’s silence and verbalization to the assistant increased while verbalization to the child de creased. The dentist’s responses after the c h ild ’s fear-related behaviors in the verb alizatio n d im en sio n differ significantly from the verbalization re sponses after nonfear-related behav iors for the first lag. At lag 2, following child’s fear-related behaviors, the den tist’s silence or nondental verbaliza tion to the assistant decreased while dental and nondental verbalizations to the child increased. The differences in the dentists’s responses to the c h ild ’s fear- and nonfear-related behaviors are significant for dentist silence and den tal and nondental verbalization to the child.
Providing explanations, use of rhetorical questions, and patting appear to be more a function of the dentist’s interpersonal style rather than a response to the child’s behavior.
Weinstein-Others : DENTISTS’ RESPONSES TO FEAR- AND NONFEAR-RELATED BEHAVIORS IN CHILDREN ■ 39
AR TICLES
Direction, reinforcement, and questioning for feelings have the highest probabilities of reducing fear-related behaviors by the child. In the physical contact dimension after fear-related behaviors, the condi tional probability that the dentist w ill be in physical contact with the child increased for the first two lags. In the first lag, working contact, holding, and the use of restraint increased following fear-related behaviors. Assistance in p o sitio n in g decreased. F ollow in g nonfear-related behaviors, the use of restraint decreased, while assistance increased. In lag 2, the probability of the use of restraint increased following fear-related behaviors.
Discussion Dentists were less likely to use direc tion or reinforcement (guidance di mension) after the child’s fear-related behavior. However, learning theory suggests that ignoring or failing to reinforce cooperation tends to lead to an increase in uncooperative behav iors. This is supported by the results of W einstein and associates that the probabilities of child fear behaviors decreased after the dentist uses direc tion and reinforcement.6 Dentists were more likely to use rules, coercion, and coaxing after child fear-related behav iors than after nonfear behaviors. These behaviors were found in the Weinstein study to be ineffective in reducing the child’s fear behavior. The probability for use of question ing for feelings, a behavior subcate gory of the empathy dimension, de creased immediately following fearrelated behaviors by the child, even though W ein stein and asso cia tes found that questioning for feelings is relatively effective in reducing fearrelated behaviors.6 Use of the other be haviors in the empathy dimension in creased following fear-related behav ior, but it appears, as reported previ ously, that these forms of attention to distress have little or no effect in re ducing the probabilities of fear behav iors by the child.
40 ■ JADA, Vol. 104, January 1982
As would be expected, when the c h ild b e g in s to sh o w fear- and distress-related behaviors, the den tist’s verbal and physical interactions w ith th e c h ild in c r e a se d . C on sequently, dentist silence, noncontact, and verbalization to the assistant de creased. Following nonfear behaviors, verbalizations to the child decrease, w hile verbalization to the assistant and the amount of silence by the den tist increase.
Conclusions In all, these data suggest that dentists most frequently respond to the child’s fear-related behavior with behaviors that are counterproductive or ineffec tive in reducing fear: rules, coercion, coaxing, reassurances, and putdowns. Dentists less frequently respond with behaviors such as direction, rein forcement, and questioning for feel ings, which have the highest prob abilities of reducing fear-related be haviors by the child. Some dentist’s behaviors did not vary under fear or nonfear conditions. The behaviors that were invariant were providing explanations, use of rhetorical questions, and patting. These appear to be more a function of the dentist’s interpersonal style rather than a management strategy or a re sp o n s e to th e c h ild ’s b e h a v io r . Analysis of the dentist’s responses clearly illustrated distinct differences in interactional styles. Some dentists, for exam ple, used em pathetic re sponses far more frequently than did others. It may be that the range of a particular dentist’s style varies only slightly, irrespective of the behavior of the child. Further investigations of appointments with high and low fear children treated by the same dentist w ill be conducted to test this hypothe sis. These findings, in conjunction with our study of the efficacy of specific
dentist behaviors in affecting child fear-related behaviors, present mean ingful patterns of dentist and child be havior in private practice. It appears that at least two problems exist. First, practitioners may not have the appro priate child management skills in their repertoire. In a recent survey of Wash ington State private practitioners, Domoto and associates7 reported that only 48% of the sample received some form of instruction in child manage ment when in dental school. Second, though the practitioners may have the necessary skills, they may not use th e se s k ills w h en they are m ost needed—w hen the child responds with fear-related behaviors. Instruc tion, especially training w ith vid eotape or remote broadcasting equip ment,8 may be extremely useful in add ing new skills or altering how existing skills are used. ft
T his study was funded by grant no. 1 RO l DE 04770-01 from the National Institute for Dental Research. Dr. W einstein is associate professor and acting chairperson, Mr. Getz is lecturer, and Mr. Ratener is biostatistician, departm ent of com m unity den tistry, and Dr. Domoto is associate professor and chairperson, departm ent of pedodontics, U niver sity of W ashington, Seattle, 98195. Address re print requests to Dr. Weinstein. 1. Melam ed, B.G., and others. Effects of film m odeling on the reduction of anxiety-related be haviors in individuals varying in level or previ ous experience in the stress situation. J Consult Clin Psychol 46(6):1357-1367, 1978. 2. Lautch, H. Dental phobia. Br J Psychiatry, 119:151-158, 1971. 3. Kleinknecht, R.A.; Klepac, R.K.; and Alexan der, L.D. Origins and characteristics, of fear of dentistry. JADA 86:842-848, 1973. 4. M elam ed, B.G., and others. Reduction of fear-related dental m anagem ent problem s w ith use of film ed m odeling. JADA 90(4):822-826, 1975. 5. W urster, C.A.; W einstein, P.; and Cohen, A.J. Com m unication patterns in pedodontics. Percept Mot Skils 48(1], 159-166, 1979. 6. W einstein, P., and others. The effect of den tist variables on fear-related behaviors of young children. J Dent Res 60(Special Issue A): 193, 1981. 7. Domoto, P.; W einstein, P.; and Getz, T. A pilot study using remote broadcasting equipm ent to provide instruction in pedodontics. J Dent Ed 43(11 pt 1): 599-601, 1979. 8. Domoto, P.; W einstein, P.; and Getz, T. Dif ficult children: experiences of 145 W ashington State private practitioners. Pediatr Dent, to be published.
child appears to result in more fearrelated behaviors. This study has begun to specify be havioral interactions during routine treatm ent of young children. A d d i tional studies of other populations of children, such as school-age children, are needed. Moreover, the m ethodol ogy used in this study has the potential to assess the effects of not only behav iors, but also pharm acological m an agem ent of patients. W hat is learned from these studies may be of consider able benefit to both providers and den tal students. CT'aT',
This study was funded by grant no. 1 RO 1 DE 04770-01 from the N ational Institute for Dental Research. 1. Forgione, A.G., and Clark, R.E. Com ments on an em pirical study of the cause of dental fears. J Dent Res 53:496, 1974. 2. Shoben, E.M., and Borland, L. An em pirical study of the etiology of dental fears. J Clin Psychol 10:17-174, 1954.
3. Lautch, H. Dental phobia. Br J Psychiatry 119:151-158, 1971. 4. Kleinknecht, R.A.; Klepac, R.K., and A lexan der, L.D. O rigins and characteristics of fear of dentistry. JADA 86:842-848, 1973. 5. B ernstein, D.A.; K leinknecht, R.A.; and Alexander, L.D.Antecedents of dental fear.J Pub lic Health Dent 39(2):113-124, 1979. 6. W einstein, P. Identifying patterns of behav ior during treatm ent of children. In Ingersoll, B., and M cKutcheon, W. eds. Proceedings of the Sec ond N ational Conference on Behavioral Dentistry: Clinical Research in Behavioral Dentistry, Mor gantow n, WVa Univ of West Virginia Press, 1980. 7. Getz, T.; W einstein, P.; and Domoto, P. The effect of structural variables on child behavior in the operatory. Pediatr Dent, to be published. 8. Domoto, P.K.; W einstein, P.; and Getz, T. A pilot study using remote broadcasting equipm ent to provide instruction in pedodontics.J Dent Educ 4 3 (llptl):599-601, 1979. 9. W urster, C.A.; W einstein, P.; and Cohen, A.J. Com m unication patterns in pedodontics. Percept Mot Skills 48(1):159-166, 1979. 10. Glennon, B., and Weisz, J.R. An observa tional approach to the assessm ent of anxiety in children. J Consult Clin Psychol 46:1247-1257, 1978. 11. Sackett, G.P. M easurem ent in observational research. In Sackett, G.P., ed. Observing behavior, vol II. Baltimore, Md, University Park Press, 1978.
12. Sackett, G.P.; Stephenson, E.; and Ruppenthel, G.C. Digital data acquisition system s for ob serving behavior in laboratory and field settings. Behav Res M ethods and Instrum entation 5:344348, 1979. 13. Sackett, G.P., and others. A fortran program for lag sequential analysis of contingency and cyclicity in behavioral interaction data. Behav Res M ethods and Instrum entation, 11:366-378, 1979. 14. Howitt, J.W., and Strieker, G. Child patient responses to various dental procedures. JADA 70:70-74, 1965. 15. Langer, E.J.; Janis, I.L.; and Wolfer, J.A.Re duction of psychological stress in surgical pa tients. J Exper Soc Psychol 11:155-165, 1975. 16. Johnson, J.E.Effects of accurate expectations about sensations on the sensory and d istress com ponents of pain. J Pers Soc Psychol 27:261275, 1973. 17. Averell, J.R.Personal control over aversive stim uli and its relationship to stress. Psychol Bull 80:286-303, 1973. 18. Maccoby, E.E. Social developm ent. New York, Harcourt, Brace, Jovanovich, Inc, 1980. 19. Bernstein, L.; Bernstein, R.S.; and Dana, R.H. Interview ing: a guide for health profes sionals. New York, A ppleton-C entury-C rofts, 1974. 20. Rogers, C.R. On becoming a person. Boston, Houghton Mifflin, 1961.
Dentists’ responses to fear- and nonfear-related behaviors in children P. T. P. P.
Weinstein, PhD Getz, MS Ratener, M S Domoto, DDS, M PH
D entists m a y respond differen tly to fear- an d nonfear-related behaviors in children, an d those responses m ay influence the ch ildren’s further behavior. This study exam ines that interaction.
r
h ild re n ’s behavior in the opera tory has alw ays been of concern in dentistry. Children m ust cooperate or m ust at least passively accept treat m ent so that the dentist can com plete technical procedures. M elam ed and associates1 found that the level of fear 38 ■ JADA, Vol. 104, January 1982
experienced by the child was posi tively related to the degree of d isru p tive behavior displayed during a re storative appointm ent. Moreover, re search2'4 suggests that traum atic den tal experiences lead to the develop m ent of fear, providing support for the
supposition that the process of provid ing care is at least as im portant as the treatm ent outcome. Most research on the m anagem ent of children has been based on the tacit assum ption that the child is the prob lem and that it is his or her behavior that m ust be altered. This assum ption has led to studies designed to assess the effect of interventions to m odify the c h ild ’s behavior. Few studies have hypothesized that m anagem ent prob lems may have an iatrogenic com po n e n t, and few have a tte m p te d to exam ine how the dentist’s behaviors influence treatm ent outcome.
ARTICLES
Dentists most frequently respond to the child’s fear-related behavior with those behaviors that are counterproductive and ineffective in reducing fear: rules, coercion, coaxing, reassurances, putdowns.
A pilot study by Wurster and as sociates5 examined communication patterns during pedodontic appoint ments in a dental school setting. Six teen dental students were videotaped during a restorative appointment with a child. Markov analysis techniques were u sed to ca lcu la te the prob abilities for the occurrence of specific behaviors by the child after certain be haviors by the dentist. The prob abilities for the occurrence of specific dentist behaviors after certain child behaviors were also calculated so that the pattern of behavioral interactions would be clearer. Their results suggest that child behavior is systematically related to the communication style of the practitioner, and that the behavior of the dentist is influenced by the child’s behavior. A more thorough understanding of dentist-child interactional patterns is necessary. In a field study of private p ra ctitio n ers, W e in ste in and a s sociates6 found that the incidence of fear -and distress-related behaviors by the child varied significantly after dif ferent behaviors by the dentist. This paper describes the probabilities for the occurrence of specific dentist be haviors after fear-related and nonfearrelated child behaviors.
Method The m ethods used in this study are the same as those described in the preced ing paper. In this study, the conditional prob abilities for specific dentist behaviors in each of the four dimensions follow ing fear- and nonfear-related child be haviors were compared. The signifi cance of the differences between den tist’s responses after the child’s fear and nonfear behaviors was determined by transforming the data into 2 scores and determining the probability that the differences were due to chance. Seventy-two videotapes have been analyzed, representing two sequential appointments for 36 children. Detailed
data analysis and results are available from the authors.
Results The dentists’ responses in the guid ance dim en sio n , im m ediately after fear-related behaviors by the ch ild (first lag), were less likely to be direc tion and reinforcement; whereas after nonfear-related behaviors, the dentist was more likely to use direction, and reinforcement. The difference in the d e n tis ts ’ re sp o n ses after fear- and nonfear-related behaviors is statisti cally significant. The probability that the dentist w ill use rules, coercion, and coaxing was g re a te r im m e d ia te ly after a c h ild showed fear-related behaviors and de creased after nonfear-related behav iors. The difference in the probability that the dentist w ill use rules and coax ing is significant. In the second lag after fear-related behaviors, the probability for the den tists’s use of reinforcement, rules, and coercion was sim ilar to that of the first lag. However, the only significant dif fe re n c e b e tw e e n th e d e n tis t’s re sponses after fear- and nonfear-related behaviors occurred for reinforcement; again, the dentist was more likely to use reinforcem ent after nonfear behav iors th an after fear behaviors. The probability that the dentist w ould use explanations, a frequent dentist behav ior, and rhetorical questions rem ained unchanged after the c h ild ’s fear- and n o n fear-related beh av io rs for both lags. For the first lag in the em pathy di mension, the conditional probability
that dentists w ould use reassurance, ignoring I denying, or putdow ns in creased significantly after the ch ild ’s fear-related behaviors; w hereas the pro b ab ility th a t the d en tist w ould question for feeling decreased. Fol lowing the ch ild ’s nonfear-related be haviors, questioning for feelings in creased, w hile ignoring I denying de creased. Differences betw een the den tist’s responses to fear and nonfear be haviors are statistically significant for all dentist behaviors except reassur ance. At lag 2, the probabilities for questioning for feelings, reassurance, ignoring I denying, and putdow ns in crease following fear-related behav iors by the child. Following nonfearrelate d beh av io rs, th e co n d itio n a l probabilities for all dentist behaviors did not vary from the unconditional probabilities. Differences betw een the dentist’s responses to fear and nonfear behaviors at lag 2 are significant for reassurance, ignoring I denying, and putdow ns. In the first lag of the verbalization dim ension, im m ediately following the child’s fear-related behaviors, the den tist’s dental and nondental verbaliza tion to the assistant decreased signifi cantly, w hile dental and nondental verbalizations to the child increased. Follow ing nonfear-related behaviors by the child, the dentist’s silence and verbalization to the assistant increased while verbalization to the child de creased. The dentist’s responses after the c h ild ’s fear-related behaviors in the verb alizatio n d im en sio n differ significantly from the verbalization re sponses after nonfear-related behav iors for the first lag. At lag 2, following child’s fear-related behaviors, the den tist’s silence or nondental verbaliza tion to the assistant decreased while dental and nondental verbalizations to the child increased. The differences in the dentists’s responses to the c h ild ’s fear- and nonfear-related behaviors are significant for dentist silence and den tal and nondental verbalization to the child.
Providing explanations, use of rhetorical questions, and patting appear to be more a function of the dentist’s interpersonal style rather than a response to the child’s behavior.
Weinstein-Others : DENTISTS’ RESPONSES TO FEAR- AND NONFEAR-RELATED BEHAVIORS IN CHILDREN ■ 39
AR TICLES
Direction, reinforcement, and questioning for feelings have the highest probabilities of reducing fear-related behaviors by the child. In the physical contact dimension after fear-related behaviors, the condi tional probability that the dentist w ill be in physical contact with the child increased for the first two lags. In the first lag, working contact, holding, and the use of restraint increased following fear-related behaviors. Assistance in p o sitio n in g decreased. F ollow in g nonfear-related behaviors, the use of restraint decreased, while assistance increased. In lag 2, the probability of the use of restraint increased following fear-related behaviors.
Discussion Dentists were less likely to use direc tion or reinforcement (guidance di mension) after the child’s fear-related behavior. However, learning theory suggests that ignoring or failing to reinforce cooperation tends to lead to an increase in uncooperative behav iors. This is supported by the results of W einstein and associates that the probabilities of child fear behaviors decreased after the dentist uses direc tion and reinforcement.6 Dentists were more likely to use rules, coercion, and coaxing after child fear-related behav iors than after nonfear behaviors. These behaviors were found in the Weinstein study to be ineffective in reducing the child’s fear behavior. The probability for use of question ing for feelings, a behavior subcate gory of the empathy dimension, de creased immediately following fearrelated behaviors by the child, even though W ein stein and asso cia tes found that questioning for feelings is relatively effective in reducing fearrelated behaviors.6 Use of the other be haviors in the empathy dimension in creased following fear-related behav ior, but it appears, as reported previ ously, that these forms of attention to distress have little or no effect in re ducing the probabilities of fear behav iors by the child.
40 ■ JADA, Vol. 104, January 1982
As would be expected, when the c h ild b e g in s to sh o w fear- and distress-related behaviors, the den tist’s verbal and physical interactions w ith th e c h ild in c r e a se d . C on sequently, dentist silence, noncontact, and verbalization to the assistant de creased. Following nonfear behaviors, verbalizations to the child decrease, w hile verbalization to the assistant and the amount of silence by the den tist increase.
Conclusions In all, these data suggest that dentists most frequently respond to the child’s fear-related behavior with behaviors that are counterproductive or ineffec tive in reducing fear: rules, coercion, coaxing, reassurances, and putdowns. Dentists less frequently respond with behaviors such as direction, rein forcement, and questioning for feel ings, which have the highest prob abilities of reducing fear-related be haviors by the child. Some dentist’s behaviors did not vary under fear or nonfear conditions. The behaviors that were invariant were providing explanations, use of rhetorical questions, and patting. These appear to be more a function of the dentist’s interpersonal style rather than a management strategy or a re sp o n s e to th e c h ild ’s b e h a v io r . Analysis of the dentist’s responses clearly illustrated distinct differences in interactional styles. Some dentists, for exam ple, used em pathetic re sponses far more frequently than did others. It may be that the range of a particular dentist’s style varies only slightly, irrespective of the behavior of the child. Further investigations of appointments with high and low fear children treated by the same dentist w ill be conducted to test this hypothe sis. These findings, in conjunction with our study of the efficacy of specific
dentist behaviors in affecting child fear-related behaviors, present mean ingful patterns of dentist and child be havior in private practice. It appears that at least two problems exist. First, practitioners may not have the appro priate child management skills in their repertoire. In a recent survey of Wash ington State private practitioners, Domoto and associates7 reported that only 48% of the sample received some form of instruction in child manage ment when in dental school. Second, though the practitioners may have the necessary skills, they may not use th e se s k ills w h en they are m ost needed—w hen the child responds with fear-related behaviors. Instruc tion, especially training w ith vid eotape or remote broadcasting equip ment,8 may be extremely useful in add ing new skills or altering how existing skills are used. ft
T his study was funded by grant no. 1 RO l DE 04770-01 from the National Institute for Dental Research. Dr. W einstein is associate professor and acting chairperson, Mr. Getz is lecturer, and Mr. Ratener is biostatistician, departm ent of com m unity den tistry, and Dr. Domoto is associate professor and chairperson, departm ent of pedodontics, U niver sity of W ashington, Seattle, 98195. Address re print requests to Dr. Weinstein. 1. Melam ed, B.G., and others. Effects of film m odeling on the reduction of anxiety-related be haviors in individuals varying in level or previ ous experience in the stress situation. J Consult Clin Psychol 46(6):1357-1367, 1978. 2. Lautch, H. Dental phobia. Br J Psychiatry, 119:151-158, 1971. 3. Kleinknecht, R.A.; Klepac, R.K.; and Alexan der, L.D. Origins and characteristics, of fear of dentistry. JADA 86:842-848, 1973. 4. M elam ed, B.G., and others. Reduction of fear-related dental m anagem ent problem s w ith use of film ed m odeling. JADA 90(4):822-826, 1975. 5. W urster, C.A.; W einstein, P.; and Cohen, A.J. Com m unication patterns in pedodontics. Percept Mot Skils 48(1], 159-166, 1979. 6. W einstein, P., and others. The effect of den tist variables on fear-related behaviors of young children. J Dent Res 60(Special Issue A): 193, 1981. 7. Domoto, P.; W einstein, P.; and Getz, T. A pilot study using remote broadcasting equipm ent to provide instruction in pedodontics. J Dent Ed 43(11 pt 1): 599-601, 1979. 8. Domoto, P.; W einstein, P.; and Getz, T. Dif ficult children: experiences of 145 W ashington State private practitioners. Pediatr Dent, to be published.