- Email: [email protected]
Reliability and validity of the Orthodontic Locus of Control Scale
Reliability and validity of the Orthodontic Locus of Control Scale Dr. Tedesco
Lisa A. Tedeeco, Ph.D.,* Judith E. Albino, Ph.D.,** and John J. Cunat, D.D.S., MS.*** Buffalo,
N.Y.
The Orthodontic Locus of Control (OLOC) Scale was developed to assess the ways in which persons perceive and evaluate the events that determine occlusal status and orthodontic treatment. The children’s OLOC Scale is a 34-item self-administered inventory with a g-point response format. The adult measure is a similar, 26item version of the scale. A g-item Occlusal Value Scale, was also developed for administration in conjunction with the OLOC Scale. These instruments were given to 51 children and their mothers who applied for treatment at the School of Dental Medicine‘s Orthodontic Clinic of the State University of New York at Buffalo. For validity studies, children and their mothers completed the Multidimensional Health Locus of Control (HLOC) Scaie and the Orthodontic Opinion Poll (OOP) Subscales. The internal consistency estimates for reltability on both the child and parent versions of the OLOC Scales were in the moderate to high-moderate range. Moderate to high-moderate subscale correlations offer promise for the validity and usefulness of the Orthodontic Locus of Control Scale for future research on psychologic and social responses to maiocclusion. The implications of the concept of “orthodontic locus of control” for orthodontists and parent-child treatment-related behaviors are discussed. 1965.) (AM J ORTHOD 88: 396-401,
Key words: Locus of control, orthodontic treatment-seeking, reliability, validity, responsibility for occlusal status, instrument development
A
number of psychologic theories explain how persons perceive and evaluate the behaviors and events that determine life’s course. The technical, psychologic term for this perception is locus of control. By definition, a person’s locus of control reflects his/ her beliefs as to whether or not life events are determined by personal actions or behaviors, by the actions of others, or by chance. Persons who are internally oriented believe they have control over their own lives. Persons who are externally oriented tend to believe that other people or chance factors control their lives. While research on the locus-of-control construct began well over two decades ago,‘,’ recent approaches suggest that it is more appropriately studied in relation to specific events or behavioral domains.3*4 For example, persons who express strong beliefs about their ability to control their lives may also believe that success An earlier version of this article was presented at the 60th Congress of the European orthodontic Society, Florence, Italy, May 29-June 2, 1984. This project was supported by Contract NIH-NIDR-DE-72499. *State University of New York at Buffalo, School of Dental Medicine, Departments of Fixed Rosthodontics and Behavioral Sciences. **Department of Behavioral Sciences. ***Department of Orthodontics.
in academic settings is a matter of chance.’ Several investigators have studied relationships among locusof-control orientations and health-enhancing behaviors, such as weight-reduction, automobile seat-belt use, compliance with treatment regimens, and smoking cessation.6’7 In addition, a specific measure for health locus of control has been designed to assessbeliefs regarding personal ability to control health or beliefs that health is controlled by chance factors or powerful other people.8-‘0 While general locus of control and health locus of control measures have been useful in the study of health behaviors in general, these measures are not specific enough to provide meaningful assessments of psychosocial responses to malocclusion. ” The purpose of this research was to develop a locus-of-control measure specific enough to assess the ways in which parents and children view responsibility for occlusal status and orthodontic treatment. According to social learning theory,” behavior is determined not only by a person’s locus-of-control beliefs, but also by how much the behavior is valued. The Occlusal Value Scale was developed to assessthe extent to which parents and children value proper occlusion.
Volume 88 Number 5
Orthodontic
Locus
of Control Scale
397
Table I. Orthodontic Locus of Control Scales (Children’s Form)* Internal 1. It is my own behavior that will determine whether my teeth will be crooked as I become older. 2. I am responsible for whether or not my teeth will be crooked as I become older. 3 : The person involved plays a big part in determining how soon crooked teeth will become straightened. 4. The things I do play a big part in how straight and well-spaced my teeth appear. 5. Crooked teeth will only straighten out if the person involved does something about them. 6. I have more control than my parents over whether or not I get my teeth straightened by an orthodontist. 7. The best way to keep teeth straight is by taking care of them myself. 8. I can protect myself from having problems caused by crooked teeth. External-chance 1. Luck plays a big part in how straight and well-spaced my teeth appear. 2. It is just bad luck if a person’s teeth are crooked and do not come together properly. 3. I feel I have no control over whether or not I get my teeth straightened by an orthodontist. 4. Good luck is the best way to keep teeth straight. 5. Crooked teeth will often straighten out by themselves as a person gets older. 6. There is nothing I can do to prevent problems caused by crooked teeth. 7. Fate will determine whether my teeth will be crooked as I become older. 8. Luck plays a big part in determining how soon crooked teeth will become straightened. 9. It would not matter much whether or not a person does what an orthodontist tells him or her to do. External-powerful others-parents 1. Parents play a big part in determining will be straightened. *Response
OptiOnS
are strongly
agree,
how soon crooked
agree pretty
much,
agree
External-powerful others-parents-Cont’d 2. If a person’s teeth do not come together properly, it is his or her parents’ fault. 3. Even if a dentist told me I do not need braces, my parents would take me to see an orthodontist if they thought my teeth were crooked. 4. I would not do what ah orthodontist tells me to do if my parents did not agree. 5. If a person’s teeth do not come together properly, it is his or her parents’ fault. 6. Crooked teeth will only straighten out if a person’s parents take them to get them straightened. 7. My parents have more control than I do over whether or not I get my teeth straightened by an orthodontist. 8. My parents are responsible for whether my teeth will be crooked as I become older. External-powerful others-professionals 1. My dentist or orthodontist plays a big part in how straight and well-spaced my teeth appear. 2. My dentist or orthodontist is responsible for whether my teeth will be crooked as I become older. 3. If a dentist told me I do not need braces, there would be nothing I could do about it, even if I thought my teeth were crooked. 4. I would do what an orthodontist tells me to do even if I don’t agree. 5. If 1 see a dentist or orthodontist regularly, I am less likely to have problems caused by crooked teeth. 6. The best way to keep teeth straight is by going to a dentist or orthodontist. 7. If a dentist told me I do not need braces, even if I thought my teeth were crooked, I would go along with what the dentist said. 8. It is the dentist or orthodontist that will determine whether my teeth will be crooked as I grow older. 9. Even if a dentist told me I do not need braces, I would go to see an orthodontist if I thought my teeth were crooked.
teeth
a little,
METHOD
The children’s Orthodontic Locus of Control Scale (OLOC) is a 34-item, self-administered inventory with a 6-point response format (strongly agree to strongly disagree). The parents’ measure is a similar, 2%item version of the scale. Subscales on the children’s version identify the four sources to which children attribute control or responsibility for occlusal status and orthodontic treatment-related events in their lives. The subscales also reflect the extent of control attributed by the children to each of the four sources. These sources are internal factors controlled by the individual, and external factors controlled by chance, parents, or the dentist-orthodontist. The external sources are labeled ex-
disagree
a little,
disagree
pretty
much,
and strongly
disagree,
temal-chance, external-powerful others-parents, and external-powerful others-professionals. In the parents’ measure, subscales identify three sources to which adults attribute control or responsibility for their child’s occlusal status and orthodontic treatment-related events-internal, external-chance, and extemal-powerful others-professionals. These subscales also reflect the extent of control attributed by the parents to each of the three sources. High scores on each subscale of the measures indicate greater attributions of control to the source reflected by the subscale. The Occlusal Value (OV) Scale comprises 6 items rated on a 6-point scale from strongly agree to strongly disagree. Higher scores on this scale indicate greater
398
Tedesco,
Table
Albino,
II. Orthodontic
Internal 1. If children’s
and
Locus
Cunat
of
teeth do not come
Control
Scales
together
properly.
(Parents’
Form)*
it is their
parents’
fault. protect my child from having problems caused by crooked teeth. I would not make my child do what an orthodontist tells hml or her to do if I did not agree. The best way for a child to keep teeth straight is by his or her parents’ taking care of them. Crooked teeth will only straighten out if parents take the child to get them straightened. The things I do play a big part in how straight and well-spaced my child’s teeth appear. It is my own behavior that will determine whether my child’s teeth will be crooked as he or she becomes older. 1 am responsible for whether or not my child’s teeth will be crooked as he or (she) becomes older. I can control whether or not my child gets his or her teeth straightened by an orthodontist. Parents play a big part in determining how soon their children’s crooked teeth will become straightened out.
2. I cti 3. 4. 5. 6. 7. 8. 9.
10.
External-chance
1. Luck plays a big part in determining how soon crooked teeth will become straight. 2. It would not matter much whether or not a child does what an orthodontist tells him or her to do. 3. Crooked teeth will often straighten out by themselves as a child gets older. 4. Good luck is the best way for a child to keep his or her teeth straight. 5. Fate will determine whether my child’s teeth will be crooked as he or she becomes older. *Response
options
are strongly
agree,
agree
pretQ
much,
agree
a little,
Table III. The Occlusal Value Scale* 1. Having tant in 2. Having tant in 3. Having tant ih 4. Having tant in 5. Having tant in 6. Having tant in *Response little,
teeth that determining teeth that determining teeth that determining teeth that determining teeth that determining teeth that determining options
disagree
are straight and tit together properly is imporhappiness. are straight and fit together properly is importhe amount of work you are able to do. are straight and fit together properly is imporgeneral health. are straight and fit together properly is imporrespect and admiration. are straight and fit together properly is imporphysical appearance. are straight and fit together properly is imporpopularity.
are strongly a little, disagree
agree, agree pretty much, agree a pret@ much, and strongly disagree.
value placed on perfect-normal occlusion. There is only one version of this scale and it is administered to both children and adults. Tables I and II display the child and adult OLOC Scale items; Table III displays the OV Scale items. These instruments were administered to 51 adoles-
External-cltarrcr-Cont’d I feel I have no control over whether or not my child gets his or her teeth straightened by an orthodontist. Luck plays a big part in how straight and well-spaced my child’s teeth appear. If a child’s teeth do not come together properly. it is a matter of chance. Therz is nothing I can do to prevent my child from having problems caused by crooked teeth. External-potvrt$uI
others
I. The dentist or orthodontist is responsible for whether my child’s teeth will be crooked as he or she becomes older. 2. My dentist or orthodontist plays a big part in how straight and well-spaced my child’s teeth appear. 3. Even if a dentist told me my child does not need braces, I would take my child to see an orthodontist if I thought his or her teeth were crooked. 4. The best way for a child to keep teeth straight is by going to a dentist or orthodontist. S. If my child sees a dentist or orthodontist regularly, he or she is less likely to have problems caused by crooked teeth. 6. If a dentist told me my child does not need braces, I would go along with what the dentist said, even if I thought my child’s teeth were crooked. 7. I would make my child do what an orthodontist tells him or her to do, even if I did not agree. 8. It is the dentist or orthodontist who will determine whether my child’s teeth will be crooked as he or she grows older. 9. If a dentist told me my child does not need braces, there would be nothing 1 could do about it. even if I thought his or her teeth were crooked.
disagree
u little,
disagree
pretty
much,
and strongly
disagree.
cent children and their mothers who were applying for treatment at the School of Dental Medicine’s Orthodontic Clinic of the State University of New York at Buffalo. In addition, for validity studies, children and their mothers completed the Multidimensional Health Locus of Control (HLOC) ScaleYand the Orthodontic Opinion Poll (OOP) Scale.““‘3 The HLOC Scale assessesattributions of responsibility to three factors for general health and illness-internal, external-chance, or external-powerful others. The OOP, composed of five scales, assessesthe following attitudes toward malocclusion and orthodontic treatment: concern for occlusion, wish for treatment, positive perception of treatment, relative value of treatment, and importance of occlusion. Children and their mothers independently completed the research instruments in a waiting area outside the clinic. Internal consistency reliability was evaluated by calculating alpha reliability coefficients’4 for each OLOC Scale and the OV Scale for children and adults. Items were also correlated with corresponding subscale items. From these relationships, average inter-item correla-
Vohne
88
Number
5
Orthodontic
Locus
of Control
Scale
399
Table IV. Descriptive statistics and reliability coefficients for the Orthodontic Locus of Control Scales and Occlusal Value Scale for Children and Parents N
Mean
SD
Alpha
Average inter-item correlations
Children Internal
External-chance External-parents External-professional Occlusal value
51 46 50 50 48
31.3 25.4 22.8 25.4 22.8
6.6 7.9 5.4 4.4 5.4
o.so 0.69 0.48 0.33 0.68
0.09 0.18 0.12 0.08 0.25
49 49 51 50
44.3 20.5 30.6 23.9
1.5 1.5 6.6 5.4
0.50 0.74 0.69 0.‘73
0.08 0.22 0.24 0.30
Mothers
Internal External-chance External-powerful others Occlusal value
tions were calculated for each subscale. Construct validity of the OLOC and OV Scales was evaluated by examining the correlations of each scale with the HLOC and OOP Scales. RESULTS Reliability
Descriptive statistics and reliability coefficients for the OLOC Scale and the OV Scale are presented in Table IV. The internal consistency estimates (alpha) on both the child and parent versions were in the moderate to high-moderate range, 0.33 to 0.69 and 0.50 to 0.74, respectively. The average inter-item subscale correlations were positive and in the low to moderate range. Inspection of the OLOC Scale means indicates greater agreement with internal scale items for both children and parents. Mean scores on the OV Scale for children (22.8) and parents (23.9) indicate that a higher than average value is placed on good occlusion. Total scores in this scale can range from 6 (valued little) to 36 (highly valued). Construct validity
Correlations of each OLOC Scale with the HLOC Scales and the OOP Scales are presented in Table V. More than 25% of the correlations for OLOC and OV Scales with the HLOC and OOP Scales were significant and in the appropriate direction to support construct validity of the OLOC and OV Scales. Significant (P G 0.05) moderate correlations were found between the following subscales for children: OLOC external-chance and HLOC internal ( - 0.3 l), OLOC external-chance and HLOC external-chance (0.3 l), OLOC external-chance and OOP positive perceptions of treatment ( -0.31), OLOC external-parents and HLOC internal ( - 0.35), OLOC extemal-professionals and OOP wish for treatment (0.27), and OV
and HLOC-internal (0.29). This pattern of positive and negative correlations appears to provide some evidence for the construct validity of the children’s OLOC Scale. Significant (P < 0.05) moderate correlations were found between the following subscales for parents: OLOC internal and OOP concern for occlusion (0.40), OLOC internal and OOP relative value of treatment (0.27), OLOC external-chance and HLOC internal ( -0.36), OLOC external-chance and HLOC extemalchance (0.57), OLOC external-chance and OOP concern for occlusion ( - 0.36), OLOC external-chance and OOP relative value of treatment ( - 0.3 l), OLOC external-chance and OOP importance of occlusion (-0.31), OLOC external-powerful others and HLOC internal (0.29)) OLOC external-powerful others and OOP concern for occlusion (0.30), OV and OOP relative value of treatment (0.27) and OV and OOP importance of occlusion (0.30). Except for the positive correlation between OLOC external powerful others and HLOC internal, the positive and negative patterns of these relationships appear to be in the appropriate direction, supporting the construct validity of the parents’ version of the OLOC Scales. DISCUSSION
Acceptable reliabilities for new measures of a construct like orthodontic locus of control often fall within the 0.50 to 0.60-range.15 Only one of the OLOC Scales, children’s external-professionals, fell well below these limits. The average inter-item correlations, however, were somewhat low, especially for the children’s subscales. Before any predictive studies are performed with the OLOC Scale, subscale-item revisions should be attempted. Perhaps, as Lefcourt3 suggests, items should be revised to reflect the difference between control beliefs for the selection of goals and control beliefs for
400
Tedesco, Albino,
Am. J. Orthod. November 1985
and Cunat
Table V. Correlations of Orthodontic Locus of Control Scales with Health Locus of Control Scales and Orthodontic Opinion Poll Scales for Children and Parents’ Health
Locus
of Control Scales
(HLOC)
Internal
External chance
External powerful others
Children Internal External-chance External-parents Extenial-professionals Occlusal value
0.11 -0.31* -0.35* 0.07 0.29*
- 0.01 0.31* 0.06 - 0.03 0.03
0.21 -0.03 0.22 0.07 -0.14
Mothers Internal External-chance External-powerful Occlusal value
0.03 -0.36* 0.29* 0.19
-0.22 0.57** -0.15 0.13
0.17 0.24 0.10 0.12
Orthodontic Locus of Control (OLOC) Scales
*Significant, **Significant,
others
Orthodontic
Concern
Opinion Scales
Pool (OOP)
occlusion
Wish for treatment
Positive perception treatment
Relative value
importance of occlusion
-0.00 -0.26 - 0.06 0.07 0.09
0.15 -0.12 - 0.05 0.27* -0.03
0.18 -0.31* -0.17 -0.01 0.11
0.00 -0.11 -0.10 -0.18 0.23
0.25 -0.16 0.15 -0.09 0.16
-0.21
0.27* -0.31* 0.17 0.27*
0.15 - 0.32* -0.04 0.30*
for
0.40** - 0.36* 0.30* 0.07
0.19 0.17 0.21 0.21
-0.11
- 0.07 0.09
P 5 0.05. P 5 0.01.
the accomplishment of goals. This may be extremely pertinent to perceptions of occlusal status and control over personal or family decisions and actions for orthodontic treatment. For example, an adolescent, or even an adult, may believe he needs orthodontic treatment, but the accomplishment of this goal may be impeded by financial barriers, perceived age barriers (“adults look childish in braces”), parental or peer perceptions that treatment is unnecessary, or professional evaluations mitigating the need for treatment. Items to distinguish between deciding on goals and accomplishing goals on the children’s OLOC Scale, in particular, may also provide stronger correlations with the HLOC Scales, For validity purposes, the internal and external scales should be moderately and negatively correlated; correlations of internal OLOC with internal HLOC Scales and external OLOC with external HLOC Scales should be moderately but positively correlated. I6 These patterns did occur and for some scales the relationships were substantial enough to satisfy discriminant validity criteria (correlations between 0.25 and 0.65). Occlusal Value assessments demonstrated weak relationships with HLOC External Scales and moderate relationships with HLOC Internal Scales for both children and adults (r = 0.29 and 0.19, respectively). Although these findings are preliminary, they reflect both theoretic notions and empiric results on the interaction between value of a behavior or event and expectancies for control of the behavior or event.3 Social learning theory” suggests that the potential for behavior is a function of both expectancies for control of the outcome
and the value placed on the outcome. Other confirming data for the validity of the OV Scale are provided by the correlation between OV and OOP relative value of treatment (r = 0.27) and importance of occlusion (r = 0.30). To enhance the understanding and prediction of behavior, RotterI recommended the development of situation-specific locus of scales measures for various categories of behaviors. For this reason the relationship between OLOC and OOP Scales was inspected. Parents’ OLOC assessments had stronger correlations with OOP Scales than did children’s OLOC assessments. Mothers’ OLOC internal scores were positively and significantly correlated with concern for occlusion (r = 0.40) and relative value of treatment (r = 0.27). These relationships were essentially zero for children; for parents, OLOC external-chance orientations were negatively and significantly GWrelated for three of the five OOP Scales. For children, these relationships were negative but nonsignificant. These findings are promising since they begin to clarify the appropriate degree of generality and specificity for control beliefs in the prediction of orthodontic treatment-seeking and attitudes toward treatment. One of the most important developments in the locus-of-control area is that a person’s perception of control varies with the situation; as situations change or as a person’s experiences change, so too may their control beliefs change. If the reliability of the OLOC Scales can be improved, it may be useful in the enhancement of patient compliance and cooperation in orthodontic treatment. For example, if an orthodontist knew that a
Volume 88 Number 5
young patient held external control beliefs, orthodontist-patient communication could be tailored so that the orthodontist would on a consistent schedule gently challenge the patient’s perceptions of no personal control and reinforce the patient’s attempts to take responsibility for such things as headgear use or rubber-band replacement. Or, if the patient were a rebellious adolescent with high internal-control beliefs, all the orthodontist may need to do, on a consistent schedule, is point out the cause-effect relationship between compliance and progress toward treatment goals. Progress toward the patient’s goal, improved dental-facial esthetics, is highly visible to the patient and to others. Recognition of this progress may be a powerful reinforcer or motivator for enhancing compliance. While there are numerous approaches to enhancing patient compliance that require careful planning and execution, it can be done.” Using locus of control measures in the design and implementation of these strategies may be important and should be done in collaboration with a behavioral scientist. This area is ripe with opportunity for interdisciplinary research. The authors wish to thank Dr. R. N. Fox for his earlier contributions to this research. REFERENCES 1. Rotter JB: Generalized expectancies for internal versus external control of reinforcement. Psycho1 Monogr 80: no. 609, 1966. 2. Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessment methods. New York, 1981, Academic Press. 3. Lefcourt HM: Locus of control: Current trends in theory and research. Hillsdale, N.J., 1976, Lawrence Erlbaum Associates. 4. Lefcourt HM: Overview. In Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessment methods. New York, 1981(a), Academic Press. 5. Crandall VC, Katkovsky W, Crandall VJ: Children’s beliefs in their own control of reinforcement in intellectual-academic situations. Child Dev 36: 91-109. 1965.
Orthodontic
Locus of Control Scale
401
6. Wallston BS, Wallston KA: Locus of control and health: A review of the literature. Health Educ Monogr 6: 107-117, 1978. 7. DiMatteo MR, DiNicola DD: Achieving patient compliance: The psychology of the medical practitioner’s role. New York, 1982, Pergamon Press. 8. Wallston BS, Wallston KA, Kaplan GD, Maides SA: Development and validation of the Health Locus of Control (HLC) Scale. J Consult Clin Psycho1 44: 580-585, 1976. 9. Wallston KA, Wallston BS, DeVellis R: Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Educ Monogr 6: 161-170, 1978. 10. Wallston KA, Wallston BS: Health locus of control scales. In Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessmentmethods. New York, 1981, Academic Press. 11. Albino JE: Development of methodologies for behavioral measurements related to malocclusion: Final report. Contract NOIDE-72499, Bethesda, Maryland, 1981, National Institute of Dental Research. 12. Rotter JB: Social learning and clinical psychology. Englewood Cliffs, N.J., 1954, Prentice-Hall. 13. Fox RN, Albino JE, Green LJ, Farr SD, Tedesco LA: Development and validation of a measure of attitudes toward malocclusion. J Dent Res 61: 1039-1043, 1982. 14. Cronbach LJ: Coefficient alpha and the internal structure of tests. Psychometrika 16: 297-334, 1951. 15. Nunnally JC: Psychometric theory. New York, 1967, McGrawHill Book Company. 16. Levenson H: Differentiating among internality, powerful others, and chance. In Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessment methods. New York, 1981, Academic Press. 17. Rotter JB: Some problems and misconceptions related to the construct of internal vs. external control of reinforcement. J Consult Clin Psycho1 43: 56-57, 1975. 18. Kanfer FH, Goldstein AP: Helping people change. New York, 1980, Pergamon Press. Reprint requests to: Dr. Lisa A. Tedesco Department of Fixed Prosthodontics School of Dental Medicine 240-F Farber Hall Buffalo, NY 14214
Lisa A. Tedeeco, Ph.D.,* Judith E. Albino, Ph.D.,** and John J. Cunat, D.D.S., MS.*** Buffalo,
N.Y.
The Orthodontic Locus of Control (OLOC) Scale was developed to assess the ways in which persons perceive and evaluate the events that determine occlusal status and orthodontic treatment. The children’s OLOC Scale is a 34-item self-administered inventory with a g-point response format. The adult measure is a similar, 26item version of the scale. A g-item Occlusal Value Scale, was also developed for administration in conjunction with the OLOC Scale. These instruments were given to 51 children and their mothers who applied for treatment at the School of Dental Medicine‘s Orthodontic Clinic of the State University of New York at Buffalo. For validity studies, children and their mothers completed the Multidimensional Health Locus of Control (HLOC) Scaie and the Orthodontic Opinion Poll (OOP) Subscales. The internal consistency estimates for reltability on both the child and parent versions of the OLOC Scales were in the moderate to high-moderate range. Moderate to high-moderate subscale correlations offer promise for the validity and usefulness of the Orthodontic Locus of Control Scale for future research on psychologic and social responses to maiocclusion. The implications of the concept of “orthodontic locus of control” for orthodontists and parent-child treatment-related behaviors are discussed. 1965.) (AM J ORTHOD 88: 396-401,
Key words: Locus of control, orthodontic treatment-seeking, reliability, validity, responsibility for occlusal status, instrument development
A
number of psychologic theories explain how persons perceive and evaluate the behaviors and events that determine life’s course. The technical, psychologic term for this perception is locus of control. By definition, a person’s locus of control reflects his/ her beliefs as to whether or not life events are determined by personal actions or behaviors, by the actions of others, or by chance. Persons who are internally oriented believe they have control over their own lives. Persons who are externally oriented tend to believe that other people or chance factors control their lives. While research on the locus-of-control construct began well over two decades ago,‘,’ recent approaches suggest that it is more appropriately studied in relation to specific events or behavioral domains.3*4 For example, persons who express strong beliefs about their ability to control their lives may also believe that success An earlier version of this article was presented at the 60th Congress of the European orthodontic Society, Florence, Italy, May 29-June 2, 1984. This project was supported by Contract NIH-NIDR-DE-72499. *State University of New York at Buffalo, School of Dental Medicine, Departments of Fixed Rosthodontics and Behavioral Sciences. **Department of Behavioral Sciences. ***Department of Orthodontics.
in academic settings is a matter of chance.’ Several investigators have studied relationships among locusof-control orientations and health-enhancing behaviors, such as weight-reduction, automobile seat-belt use, compliance with treatment regimens, and smoking cessation.6’7 In addition, a specific measure for health locus of control has been designed to assessbeliefs regarding personal ability to control health or beliefs that health is controlled by chance factors or powerful other people.8-‘0 While general locus of control and health locus of control measures have been useful in the study of health behaviors in general, these measures are not specific enough to provide meaningful assessments of psychosocial responses to malocclusion. ” The purpose of this research was to develop a locus-of-control measure specific enough to assess the ways in which parents and children view responsibility for occlusal status and orthodontic treatment. According to social learning theory,” behavior is determined not only by a person’s locus-of-control beliefs, but also by how much the behavior is valued. The Occlusal Value Scale was developed to assessthe extent to which parents and children value proper occlusion.
Volume 88 Number 5
Orthodontic
Locus
of Control Scale
397
Table I. Orthodontic Locus of Control Scales (Children’s Form)* Internal 1. It is my own behavior that will determine whether my teeth will be crooked as I become older. 2. I am responsible for whether or not my teeth will be crooked as I become older. 3 : The person involved plays a big part in determining how soon crooked teeth will become straightened. 4. The things I do play a big part in how straight and well-spaced my teeth appear. 5. Crooked teeth will only straighten out if the person involved does something about them. 6. I have more control than my parents over whether or not I get my teeth straightened by an orthodontist. 7. The best way to keep teeth straight is by taking care of them myself. 8. I can protect myself from having problems caused by crooked teeth. External-chance 1. Luck plays a big part in how straight and well-spaced my teeth appear. 2. It is just bad luck if a person’s teeth are crooked and do not come together properly. 3. I feel I have no control over whether or not I get my teeth straightened by an orthodontist. 4. Good luck is the best way to keep teeth straight. 5. Crooked teeth will often straighten out by themselves as a person gets older. 6. There is nothing I can do to prevent problems caused by crooked teeth. 7. Fate will determine whether my teeth will be crooked as I become older. 8. Luck plays a big part in determining how soon crooked teeth will become straightened. 9. It would not matter much whether or not a person does what an orthodontist tells him or her to do. External-powerful others-parents 1. Parents play a big part in determining will be straightened. *Response
OptiOnS
are strongly
agree,
how soon crooked
agree pretty
much,
agree
External-powerful others-parents-Cont’d 2. If a person’s teeth do not come together properly, it is his or her parents’ fault. 3. Even if a dentist told me I do not need braces, my parents would take me to see an orthodontist if they thought my teeth were crooked. 4. I would not do what ah orthodontist tells me to do if my parents did not agree. 5. If a person’s teeth do not come together properly, it is his or her parents’ fault. 6. Crooked teeth will only straighten out if a person’s parents take them to get them straightened. 7. My parents have more control than I do over whether or not I get my teeth straightened by an orthodontist. 8. My parents are responsible for whether my teeth will be crooked as I become older. External-powerful others-professionals 1. My dentist or orthodontist plays a big part in how straight and well-spaced my teeth appear. 2. My dentist or orthodontist is responsible for whether my teeth will be crooked as I become older. 3. If a dentist told me I do not need braces, there would be nothing I could do about it, even if I thought my teeth were crooked. 4. I would do what an orthodontist tells me to do even if I don’t agree. 5. If 1 see a dentist or orthodontist regularly, I am less likely to have problems caused by crooked teeth. 6. The best way to keep teeth straight is by going to a dentist or orthodontist. 7. If a dentist told me I do not need braces, even if I thought my teeth were crooked, I would go along with what the dentist said. 8. It is the dentist or orthodontist that will determine whether my teeth will be crooked as I grow older. 9. Even if a dentist told me I do not need braces, I would go to see an orthodontist if I thought my teeth were crooked.
teeth
a little,
METHOD
The children’s Orthodontic Locus of Control Scale (OLOC) is a 34-item, self-administered inventory with a 6-point response format (strongly agree to strongly disagree). The parents’ measure is a similar, 2%item version of the scale. Subscales on the children’s version identify the four sources to which children attribute control or responsibility for occlusal status and orthodontic treatment-related events in their lives. The subscales also reflect the extent of control attributed by the children to each of the four sources. These sources are internal factors controlled by the individual, and external factors controlled by chance, parents, or the dentist-orthodontist. The external sources are labeled ex-
disagree
a little,
disagree
pretty
much,
and strongly
disagree,
temal-chance, external-powerful others-parents, and external-powerful others-professionals. In the parents’ measure, subscales identify three sources to which adults attribute control or responsibility for their child’s occlusal status and orthodontic treatment-related events-internal, external-chance, and extemal-powerful others-professionals. These subscales also reflect the extent of control attributed by the parents to each of the three sources. High scores on each subscale of the measures indicate greater attributions of control to the source reflected by the subscale. The Occlusal Value (OV) Scale comprises 6 items rated on a 6-point scale from strongly agree to strongly disagree. Higher scores on this scale indicate greater
398
Tedesco,
Table
Albino,
II. Orthodontic
Internal 1. If children’s
and
Locus
Cunat
of
teeth do not come
Control
Scales
together
properly.
(Parents’
Form)*
it is their
parents’
fault. protect my child from having problems caused by crooked teeth. I would not make my child do what an orthodontist tells hml or her to do if I did not agree. The best way for a child to keep teeth straight is by his or her parents’ taking care of them. Crooked teeth will only straighten out if parents take the child to get them straightened. The things I do play a big part in how straight and well-spaced my child’s teeth appear. It is my own behavior that will determine whether my child’s teeth will be crooked as he or she becomes older. 1 am responsible for whether or not my child’s teeth will be crooked as he or (she) becomes older. I can control whether or not my child gets his or her teeth straightened by an orthodontist. Parents play a big part in determining how soon their children’s crooked teeth will become straightened out.
2. I cti 3. 4. 5. 6. 7. 8. 9.
10.
External-chance
1. Luck plays a big part in determining how soon crooked teeth will become straight. 2. It would not matter much whether or not a child does what an orthodontist tells him or her to do. 3. Crooked teeth will often straighten out by themselves as a child gets older. 4. Good luck is the best way for a child to keep his or her teeth straight. 5. Fate will determine whether my child’s teeth will be crooked as he or she becomes older. *Response
options
are strongly
agree,
agree
pretQ
much,
agree
a little,
Table III. The Occlusal Value Scale* 1. Having tant in 2. Having tant in 3. Having tant ih 4. Having tant in 5. Having tant in 6. Having tant in *Response little,
teeth that determining teeth that determining teeth that determining teeth that determining teeth that determining teeth that determining options
disagree
are straight and tit together properly is imporhappiness. are straight and fit together properly is importhe amount of work you are able to do. are straight and fit together properly is imporgeneral health. are straight and fit together properly is imporrespect and admiration. are straight and fit together properly is imporphysical appearance. are straight and fit together properly is imporpopularity.
are strongly a little, disagree
agree, agree pretty much, agree a pret@ much, and strongly disagree.
value placed on perfect-normal occlusion. There is only one version of this scale and it is administered to both children and adults. Tables I and II display the child and adult OLOC Scale items; Table III displays the OV Scale items. These instruments were administered to 51 adoles-
External-cltarrcr-Cont’d I feel I have no control over whether or not my child gets his or her teeth straightened by an orthodontist. Luck plays a big part in how straight and well-spaced my child’s teeth appear. If a child’s teeth do not come together properly. it is a matter of chance. Therz is nothing I can do to prevent my child from having problems caused by crooked teeth. External-potvrt$uI
others
I. The dentist or orthodontist is responsible for whether my child’s teeth will be crooked as he or she becomes older. 2. My dentist or orthodontist plays a big part in how straight and well-spaced my child’s teeth appear. 3. Even if a dentist told me my child does not need braces, I would take my child to see an orthodontist if I thought his or her teeth were crooked. 4. The best way for a child to keep teeth straight is by going to a dentist or orthodontist. S. If my child sees a dentist or orthodontist regularly, he or she is less likely to have problems caused by crooked teeth. 6. If a dentist told me my child does not need braces, I would go along with what the dentist said, even if I thought my child’s teeth were crooked. 7. I would make my child do what an orthodontist tells him or her to do, even if I did not agree. 8. It is the dentist or orthodontist who will determine whether my child’s teeth will be crooked as he or she grows older. 9. If a dentist told me my child does not need braces, there would be nothing 1 could do about it. even if I thought his or her teeth were crooked.
disagree
u little,
disagree
pretty
much,
and strongly
disagree.
cent children and their mothers who were applying for treatment at the School of Dental Medicine’s Orthodontic Clinic of the State University of New York at Buffalo. In addition, for validity studies, children and their mothers completed the Multidimensional Health Locus of Control (HLOC) ScaleYand the Orthodontic Opinion Poll (OOP) Scale.““‘3 The HLOC Scale assessesattributions of responsibility to three factors for general health and illness-internal, external-chance, or external-powerful others. The OOP, composed of five scales, assessesthe following attitudes toward malocclusion and orthodontic treatment: concern for occlusion, wish for treatment, positive perception of treatment, relative value of treatment, and importance of occlusion. Children and their mothers independently completed the research instruments in a waiting area outside the clinic. Internal consistency reliability was evaluated by calculating alpha reliability coefficients’4 for each OLOC Scale and the OV Scale for children and adults. Items were also correlated with corresponding subscale items. From these relationships, average inter-item correla-
Vohne
88
Number
5
Orthodontic
Locus
of Control
Scale
399
Table IV. Descriptive statistics and reliability coefficients for the Orthodontic Locus of Control Scales and Occlusal Value Scale for Children and Parents N
Mean
SD
Alpha
Average inter-item correlations
Children Internal
External-chance External-parents External-professional Occlusal value
51 46 50 50 48
31.3 25.4 22.8 25.4 22.8
6.6 7.9 5.4 4.4 5.4
o.so 0.69 0.48 0.33 0.68
0.09 0.18 0.12 0.08 0.25
49 49 51 50
44.3 20.5 30.6 23.9
1.5 1.5 6.6 5.4
0.50 0.74 0.69 0.‘73
0.08 0.22 0.24 0.30
Mothers
Internal External-chance External-powerful others Occlusal value
tions were calculated for each subscale. Construct validity of the OLOC and OV Scales was evaluated by examining the correlations of each scale with the HLOC and OOP Scales. RESULTS Reliability
Descriptive statistics and reliability coefficients for the OLOC Scale and the OV Scale are presented in Table IV. The internal consistency estimates (alpha) on both the child and parent versions were in the moderate to high-moderate range, 0.33 to 0.69 and 0.50 to 0.74, respectively. The average inter-item subscale correlations were positive and in the low to moderate range. Inspection of the OLOC Scale means indicates greater agreement with internal scale items for both children and parents. Mean scores on the OV Scale for children (22.8) and parents (23.9) indicate that a higher than average value is placed on good occlusion. Total scores in this scale can range from 6 (valued little) to 36 (highly valued). Construct validity
Correlations of each OLOC Scale with the HLOC Scales and the OOP Scales are presented in Table V. More than 25% of the correlations for OLOC and OV Scales with the HLOC and OOP Scales were significant and in the appropriate direction to support construct validity of the OLOC and OV Scales. Significant (P G 0.05) moderate correlations were found between the following subscales for children: OLOC external-chance and HLOC internal ( - 0.3 l), OLOC external-chance and HLOC external-chance (0.3 l), OLOC external-chance and OOP positive perceptions of treatment ( -0.31), OLOC external-parents and HLOC internal ( - 0.35), OLOC extemal-professionals and OOP wish for treatment (0.27), and OV
and HLOC-internal (0.29). This pattern of positive and negative correlations appears to provide some evidence for the construct validity of the children’s OLOC Scale. Significant (P < 0.05) moderate correlations were found between the following subscales for parents: OLOC internal and OOP concern for occlusion (0.40), OLOC internal and OOP relative value of treatment (0.27), OLOC external-chance and HLOC internal ( -0.36), OLOC external-chance and HLOC extemalchance (0.57), OLOC external-chance and OOP concern for occlusion ( - 0.36), OLOC external-chance and OOP relative value of treatment ( - 0.3 l), OLOC external-chance and OOP importance of occlusion (-0.31), OLOC external-powerful others and HLOC internal (0.29)) OLOC external-powerful others and OOP concern for occlusion (0.30), OV and OOP relative value of treatment (0.27) and OV and OOP importance of occlusion (0.30). Except for the positive correlation between OLOC external powerful others and HLOC internal, the positive and negative patterns of these relationships appear to be in the appropriate direction, supporting the construct validity of the parents’ version of the OLOC Scales. DISCUSSION
Acceptable reliabilities for new measures of a construct like orthodontic locus of control often fall within the 0.50 to 0.60-range.15 Only one of the OLOC Scales, children’s external-professionals, fell well below these limits. The average inter-item correlations, however, were somewhat low, especially for the children’s subscales. Before any predictive studies are performed with the OLOC Scale, subscale-item revisions should be attempted. Perhaps, as Lefcourt3 suggests, items should be revised to reflect the difference between control beliefs for the selection of goals and control beliefs for
400
Tedesco, Albino,
Am. J. Orthod. November 1985
and Cunat
Table V. Correlations of Orthodontic Locus of Control Scales with Health Locus of Control Scales and Orthodontic Opinion Poll Scales for Children and Parents’ Health
Locus
of Control Scales
(HLOC)
Internal
External chance
External powerful others
Children Internal External-chance External-parents Extenial-professionals Occlusal value
0.11 -0.31* -0.35* 0.07 0.29*
- 0.01 0.31* 0.06 - 0.03 0.03
0.21 -0.03 0.22 0.07 -0.14
Mothers Internal External-chance External-powerful Occlusal value
0.03 -0.36* 0.29* 0.19
-0.22 0.57** -0.15 0.13
0.17 0.24 0.10 0.12
Orthodontic Locus of Control (OLOC) Scales
*Significant, **Significant,
others
Orthodontic
Concern
Opinion Scales
Pool (OOP)
occlusion
Wish for treatment
Positive perception treatment
Relative value
importance of occlusion
-0.00 -0.26 - 0.06 0.07 0.09
0.15 -0.12 - 0.05 0.27* -0.03
0.18 -0.31* -0.17 -0.01 0.11
0.00 -0.11 -0.10 -0.18 0.23
0.25 -0.16 0.15 -0.09 0.16
-0.21
0.27* -0.31* 0.17 0.27*
0.15 - 0.32* -0.04 0.30*
for
0.40** - 0.36* 0.30* 0.07
0.19 0.17 0.21 0.21
-0.11
- 0.07 0.09
P 5 0.05. P 5 0.01.
the accomplishment of goals. This may be extremely pertinent to perceptions of occlusal status and control over personal or family decisions and actions for orthodontic treatment. For example, an adolescent, or even an adult, may believe he needs orthodontic treatment, but the accomplishment of this goal may be impeded by financial barriers, perceived age barriers (“adults look childish in braces”), parental or peer perceptions that treatment is unnecessary, or professional evaluations mitigating the need for treatment. Items to distinguish between deciding on goals and accomplishing goals on the children’s OLOC Scale, in particular, may also provide stronger correlations with the HLOC Scales, For validity purposes, the internal and external scales should be moderately and negatively correlated; correlations of internal OLOC with internal HLOC Scales and external OLOC with external HLOC Scales should be moderately but positively correlated. I6 These patterns did occur and for some scales the relationships were substantial enough to satisfy discriminant validity criteria (correlations between 0.25 and 0.65). Occlusal Value assessments demonstrated weak relationships with HLOC External Scales and moderate relationships with HLOC Internal Scales for both children and adults (r = 0.29 and 0.19, respectively). Although these findings are preliminary, they reflect both theoretic notions and empiric results on the interaction between value of a behavior or event and expectancies for control of the behavior or event.3 Social learning theory” suggests that the potential for behavior is a function of both expectancies for control of the outcome
and the value placed on the outcome. Other confirming data for the validity of the OV Scale are provided by the correlation between OV and OOP relative value of treatment (r = 0.27) and importance of occlusion (r = 0.30). To enhance the understanding and prediction of behavior, RotterI recommended the development of situation-specific locus of scales measures for various categories of behaviors. For this reason the relationship between OLOC and OOP Scales was inspected. Parents’ OLOC assessments had stronger correlations with OOP Scales than did children’s OLOC assessments. Mothers’ OLOC internal scores were positively and significantly correlated with concern for occlusion (r = 0.40) and relative value of treatment (r = 0.27). These relationships were essentially zero for children; for parents, OLOC external-chance orientations were negatively and significantly GWrelated for three of the five OOP Scales. For children, these relationships were negative but nonsignificant. These findings are promising since they begin to clarify the appropriate degree of generality and specificity for control beliefs in the prediction of orthodontic treatment-seeking and attitudes toward treatment. One of the most important developments in the locus-of-control area is that a person’s perception of control varies with the situation; as situations change or as a person’s experiences change, so too may their control beliefs change. If the reliability of the OLOC Scales can be improved, it may be useful in the enhancement of patient compliance and cooperation in orthodontic treatment. For example, if an orthodontist knew that a
Volume 88 Number 5
young patient held external control beliefs, orthodontist-patient communication could be tailored so that the orthodontist would on a consistent schedule gently challenge the patient’s perceptions of no personal control and reinforce the patient’s attempts to take responsibility for such things as headgear use or rubber-band replacement. Or, if the patient were a rebellious adolescent with high internal-control beliefs, all the orthodontist may need to do, on a consistent schedule, is point out the cause-effect relationship between compliance and progress toward treatment goals. Progress toward the patient’s goal, improved dental-facial esthetics, is highly visible to the patient and to others. Recognition of this progress may be a powerful reinforcer or motivator for enhancing compliance. While there are numerous approaches to enhancing patient compliance that require careful planning and execution, it can be done.” Using locus of control measures in the design and implementation of these strategies may be important and should be done in collaboration with a behavioral scientist. This area is ripe with opportunity for interdisciplinary research. The authors wish to thank Dr. R. N. Fox for his earlier contributions to this research. REFERENCES 1. Rotter JB: Generalized expectancies for internal versus external control of reinforcement. Psycho1 Monogr 80: no. 609, 1966. 2. Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessment methods. New York, 1981, Academic Press. 3. Lefcourt HM: Locus of control: Current trends in theory and research. Hillsdale, N.J., 1976, Lawrence Erlbaum Associates. 4. Lefcourt HM: Overview. In Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessment methods. New York, 1981(a), Academic Press. 5. Crandall VC, Katkovsky W, Crandall VJ: Children’s beliefs in their own control of reinforcement in intellectual-academic situations. Child Dev 36: 91-109. 1965.
Orthodontic
Locus of Control Scale
401
6. Wallston BS, Wallston KA: Locus of control and health: A review of the literature. Health Educ Monogr 6: 107-117, 1978. 7. DiMatteo MR, DiNicola DD: Achieving patient compliance: The psychology of the medical practitioner’s role. New York, 1982, Pergamon Press. 8. Wallston BS, Wallston KA, Kaplan GD, Maides SA: Development and validation of the Health Locus of Control (HLC) Scale. J Consult Clin Psycho1 44: 580-585, 1976. 9. Wallston KA, Wallston BS, DeVellis R: Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Educ Monogr 6: 161-170, 1978. 10. Wallston KA, Wallston BS: Health locus of control scales. In Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessmentmethods. New York, 1981, Academic Press. 11. Albino JE: Development of methodologies for behavioral measurements related to malocclusion: Final report. Contract NOIDE-72499, Bethesda, Maryland, 1981, National Institute of Dental Research. 12. Rotter JB: Social learning and clinical psychology. Englewood Cliffs, N.J., 1954, Prentice-Hall. 13. Fox RN, Albino JE, Green LJ, Farr SD, Tedesco LA: Development and validation of a measure of attitudes toward malocclusion. J Dent Res 61: 1039-1043, 1982. 14. Cronbach LJ: Coefficient alpha and the internal structure of tests. Psychometrika 16: 297-334, 1951. 15. Nunnally JC: Psychometric theory. New York, 1967, McGrawHill Book Company. 16. Levenson H: Differentiating among internality, powerful others, and chance. In Lefcourt HM (editor): Research with the locus of control construct. Vol. 1, Assessment methods. New York, 1981, Academic Press. 17. Rotter JB: Some problems and misconceptions related to the construct of internal vs. external control of reinforcement. J Consult Clin Psycho1 43: 56-57, 1975. 18. Kanfer FH, Goldstein AP: Helping people change. New York, 1980, Pergamon Press. Reprint requests to: Dr. Lisa A. Tedesco Department of Fixed Prosthodontics School of Dental Medicine 240-F Farber Hall Buffalo, NY 14214