Document Type : Original article
Introduction
Successful and safe provision of dental care for children highly depends on the behavioral management of children (1). Challenges associated with the management of pediatric dental patients led to development of different behavioral management techniques (2).
A high level of diversity exists in physical, mental, emotional, and social characteristics, attitude, and behavior of children, which should be taken into account in addition to the level of growth and development of children to ensure success of dental treatments (3). Dental clinicians should be well aware of different behavioral management techniques, and have the required level of skills and flexibility in their implementation (4). Knowledge about the behavioral management techniques is imperative for provision of high-quality dental care and establishment of a positive and reliable relationship with not only children, but also adults with cognitive impairments (1). Such skills obviate the patients’ dental needs in the short-term and guarantee public health promotion in the long-term (5).
In the recent years, the term “behavioral management” was suggested as a replacement for the term “behavioral control” to further emphasize on the importance of establishment of a relationship with the parents and children to obviate their healthcare needs (1). The main goal is to provide high-quality care safely in a setting acceptable by children, and create a positive attitude towards oral health and dental care in them (1). An optimal patient-clinician relationship is much more challenging to build in children compared with adults (6). Evidence shows that uncooperative children with dental fear and anxiety have a higher prevalence of caries and dental pain (7).
The American Academy of Pediatric Dentistry classifies the behavioral management techniques into two main categories of basic and advanced (1). The basic techniques include the Tell-Show-Do (TSD), voice control, positive reinforcement, distraction, and parent separation techniques; while, the advanced techniques include active and passive restraint, sedation, and general anesthesia (1).
Pediatric dentists select a behavioral management technique based on the patients’ history and needs, type of treatment required, emotional and mental development of children, parental preferences, and their own capabilities and skills (8). Depending on patient conditions, dental clinicians may use a combination of basic and advanced techniques (2). An efficient technique for a particular child may not be suitable for others (6). Dental clinician, child, and parents comprise the three corners of the pediatric dentistry treatment triangle. An efficient communication among the three is imperative for optimal provision of high-quality care (9).
In today’s world, parents are more involved in decision-making regarding dental treatment of their children compared with before. They are emotionally and legally responsible for their children (10). Therefore, their acceptance of the procedure and the adopted behavioral management technique is highly important and should be taken into account to prevent legal problems (11,12). The attitude of the parents towards the behavioral management techniques can affect the quality of their provision and the treatment outcome (2). The behavioral needs of children often vary depending on the parenting style, which should be taken into account along with the attitude of the parents towards the behavioral management techniques (6,12). The parenting style indicates the attitude of the parents towards their children and is defined as the pattern of behaviors, attitudes, and approaches adopted by the parents when interacting with their children (13). Baumrind (14) defined three distinct parenting styles of authoritative, authoritarian, and the permissive style based on the level of communication and the standards set by the parents for their children.
Authoritative parents are highly responsive (intimacy) and demanding (control). These parents use logical reasoning to raise their children, listen to their children, do not use punitive measures, and provide the basis for their children’s independence. Authoritarian parents display high levels of demandingness (control) and low levels of responsiveness (intimacy). They have high demands on their children and use control and coercion to achieve their absolute standards. If children do not adhere to the rules, they punish them and damage their children’s self-esteem by using statements such as “My child will never wear this” or “He/She is not capable of doing this”. They verbally and emotionally abuse their children because they have not met their parents’ expectations. Although both authoritative and authoritarian parents are highly demanding of their children, the way they exercise control is different. Unlike the authoritarian parents, authoritative parents use logical reasoning to explain rules. In the permissive style, parents do not feel responsible for their child’s behavior and actions and leave the child free. Usually, there is a sort of chaos in such families, because no restrictions are imposed by the parents, and the parents accept the wishes of their children without any question (15). Evidence supports a potential relationship between the parenting style and children’s behavior (16-19), but the impact of parenting style on parents’ preferences for different behavioral management techniques has not been well investigated.
The level of acceptance of different behavioral management techniques by the parents is widely variable, and influenced by several parameters, including their parenting style. Evidence shows that some disagreements may exist between the parents regarding the behavioral management techniques and dental clinicians’ preferences (11). Evidence supports the presence of a potential correlation between the parenting style and behavior of children (20-23); however, the effect of parenting style on parental preferences with respect to behavioral management techniques requires further investigations. Thus, this study aimed to assess the relationship of the parenting style with parental acceptance of the behavioral management techniques for pediatric dental patients. The null hypothesis of the study was that parenting style would have no significant association with parental acceptance of the behavioral management techniques.
Materials and Methods
This cross-sectional study was conducted on parents of 64 children between 3-6 years who had their first dental visit at the Pediatric Dentistry Department of Tehran University of Medical Sciences in the spring of 2024.
Sample size
The sample size was calculated to be 64 according to a study by Al Zoubi et al (12), assuming the mean and standard deviation of N2O sedation score to be 3.78 and 1.34, respectively, and alpha=0.05.
Eligibility criteria
The inclusion criteria were children between 3-6 years requiring dental treatments and having their first dental visit, willingness of the parents for participation in the study, and psychological health of the parents.
The exclusion criteria were children with systemic diseases, cognitive impairments, or psychological disorders, and single parents.
Data collection
Information about the parenting style was collected using the Persian version of the Parenting Styles and Dimensions Questionnaire (PSDQ). The validity and reliability of the Persian version of PSDQ were confirmed by Morowatisharifabad et al (24). The questionnaire had three parts. The first part asked for demographic information of the parents including their age, sex, level of education, and occupation. The second part included the Persian version of the PSDQ with 32 questions with 5-point Likert scale answer choices from 1: never to 5: always. Of all, 15 questions were related to the authoritative style (questions 1, 3, 5, 7, 9, 11, 12, 14, 18, 21, 22, 25, 27, 29, and 31), 12 questions were related to the authoritarian style (questions 2, 4, 6, 10, 13, 16, 19, 23, 26, 28, 30, and 32), and 5 questions were related to the permissive style (questions 8, 15, 17, 20, and 24). The answer choices were never, once in a while, about half of the time, very often, and always, that were scored 1 to 5.
The third part consisted of 8 questions assessing parental acceptance of behavioral management techniques. Four questions assessed parental acceptance of techniques used for cooperative children, including positive reinforcement, tell-show-do, parent separation, and voice control. Four additional questions assessed parental acceptance of techniques used for uncooperative children, including general anesthesia, nitrous oxide sedation, active restraint, and passive restraint. Parents rated their acceptance of each technique using a 5-point Likert scale consisting of totally disagree, disagree, no opinion, agree, and totally agree. The responses were scored from 0 to 4.
The eligible parents who were willing to participate in the study were guided to a room where their children could draw a picture while they were watching a video about 8 different basic and advanced behavioral management techniques, and filling out the questionnaire with 8 questions (1 per each technique). The video showed different basic and advanced behavioral management techniques both in reality and schematically in a simple and understandable manner in Persian, and was shown on a display monitor. It explained each technique within 60 s, and the total video took 8 min to watch. Next, the parents expressed their level of acceptance of each technique by filling out the third part of the questionnaire with 5-point Likert scale answer choices of totally disagree, disagree, no opinion, agree, and totally agree, that were scored 0 to 4. They were ensured about the confidentiality of their information and the fact that their answers would not affect the course of treatment of their children. The questionnaires were then collected. The score of each parenting style was separately calculated for each parent, and the parenting style with the highest mean score was recorded as the dominant parenting style of the respective parent.
Statistical analysis
Data were analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics (means, standard deviations, and frequencies) were used to summarize demographic information and parenting styles (Tables 1-4). The parenting style and acceptance part of the questionnaire were scored out of 100 points. Statistical analyses were carried out using the Spearman’s correlation test at 0.05 level of significance.
Results
Table 1 presents the demographic information of the parents. As shown, mothers comprised 60.9% of the respondents. The majority of the parents had a Bachelor’s degree or a college degree (40.6%). The mean age of the parents was 36.6 years (range 24 to 49 years). The majority of the parents were housewives (45.4%). Tables 2-4 present the frequency of responses to the questions regarding the authoritative, authoritarian, and permissive parenting styles. Of 64 parents, 39 (60.9%) had authoritative, 15 (23.5%) had authoritarian, and 10 (15.6%) had permissive parenting style. The mean score was 2.39±0.91 (range 1.17 to 4.25) for the authoritative, 3.67±0.75 (range 2.4 to 4.87) for the authoritarian, and 2.58±1.00 (range 1 to 4.6) for the permissive style. Table 5 shows the acceptance of each behavioral management technique by the parents. The most accepted technique was positive reinforcement followed by the TSD, parent separation, and voice control for cooperative children. General anesthesia, followed by N2O sedation, and active and passive restraint were the most accepted techniques for uncooperative children. The distribution of parental responses regarding the acceptance of each behavioral management technique is presented in table 5. Table 6 shows the correlation of parenting style with parental acceptance of different behavioral management techniques. As indicated, the authoritative parenting style had a significant positive correlation with the TSD, and parent separation and a significant inverse correlation with N2O sedation and general anesthesia, showing less acceptance of these two. The authoritarian parenting style had a significant positive correlation with the voice control, active restraint, passive restraint, N2O sedation, and general anesthesia, and a significant inverse correlation with the TSD and parent separation. The permissive parenting style had a significant positive correlation with the TSD, positive reinforcement, and parent separation, and a significant inverse correlation with voice control, active restraint, and passive restraint, showing lower acceptance of the latter two in this parenting style. Exact correlation coefficients and p-values are presented in table 6.
Table 1. Demographic information of the parents
|
Variable |
Category |
Number |
Percentage |
|
Sex |
Female |
39 |
60.9 |
|
Male |
25 |
39.1 |
|
|
Level of education |
Master’s degree or higher |
9 |
14.1 |
|
Bachelor’s degree or college degree |
26 |
40.6 |
|
|
High-school diploma |
25 |
39.1 |
|
|
Below high-school diploma |
4 |
6.3 |
|
|
Illiterate |
0 |
0 |
|
|
Occupational status |
Unemployed |
0 |
0 |
|
Housewife |
29 |
45.4 |
|
|
Businessman |
15 |
23.4 |
|
|
Employee |
14 |
21.9 |
|
|
Worker |
1 |
1.6 |
|
|
Engineer |
3 |
4.6 |
|
|
Nurse |
2 |
3.1 |
Table 2. Frequency of responses to the questions regarding the authoritative parenting style
|
Question |
Never |
Once in a while |
About half of the time |
Very often |
Always |
|||||
|
N |
% |
N |
% |
N |
% |
N |
% |
N |
% |
|
|
1. I am responsive to our child’s feelings and needs |
0 |
0 |
1 |
1.6 |
4 |
6.3 |
35 |
54.7 |
24 |
37.5 |
|
3. I take our child’s desires into account before asking the child to do something |
0 |
0 |
5 |
7.8 |
26 |
40.6 |
23 |
35.9 |
10 |
15.6 |
|
5. I explain to our child how we feel about the child’s good and bad behavior |
4 |
6.3 |
9 |
14.1 |
16 |
25 |
22 |
34.4 |
13 |
20.3 |
|
7. I encourage our child to talk about his/her troubles |
2 |
3.1 |
12 |
18.8 |
12 |
18.8 |
14 |
21.9 |
24 |
37.5 |
|
9. I encourage our child to freely express himself/herself even when disagreeing with parents |
2 |
3.1 |
20 |
31.3 |
10 |
15.6 |
16 |
25 |
16 |
25 |
|
11. I emphasize the reasons for rules |
1 |
1.6 |
9 |
14.1 |
24 |
37.5 |
15 |
23.4 |
15 |
23.4 |
|
12. I give comfort and understanding when our child is upset |
0 |
0 |
5 |
7.8 |
18 |
28.1 |
22 |
34.4 |
19 |
29.7 |
|
14. I give praise when our child is good |
0 |
0 |
2 |
3.1 |
14 |
21.9 |
19 |
29.7 |
29 |
45.3 |
|
18. I take into account our child’s preferences in making plans for the family |
1 |
1.6 |
15 |
23.4 |
16 |
25 |
20 |
31.3 |
12 |
18.8 |
|
21. I show respect for our child’s opinions by encouraging our child to express them |
0 |
0 |
11 |
17.2 |
15 |
23.4 |
22 |
34.4 |
16 |
25 |
|
22. I allow our child to give input into family rules |
3 |
4.7 |
18 |
28.1 |
18 |
28.1 |
17 |
26.6 |
8 |
12.5 |
|
25. I give our child reasons why rules should be obeyed |
0 |
0 |
7 |
10.9 |
16 |
25 |
24 |
37.5 |
17 |
26.6 |
|
27. I have warm and intimate times together with our child |
0 |
0 |
5 |
7.8 |
25 |
39.1 |
15 |
23.4 |
19 |
29.7 |
|
29. I help our child to understand the impact of behavior by encouraging our child to talk about the consequences of his/her own actions |
0 |
0 |
10 |
15.6 |
20 |
31.3 |
23 |
35.9 |
11 |
17.2 |
|
31. I explain the consequences of the child’s behavior |
1 |
1.6 |
8 |
12.5 |
13 |
20.3 |
22 |
34.4 |
20 |
31.3 |
Table 3. Frequency of responses to the questions regarding the authoritarian parenting style
|
Question |
Never |
Once in a while |
About half of the time |
Very often |
Always |
|||||
|
N |
% |
N |
% |
N |
% |
N |
% |
N |
% |
|
|
2. I use physical punishment as a way of disciplining our child |
21 |
32.8 |
25 |
39.1 |
16 |
25 |
2 |
3.1 |
0 |
0 |
|
4. When our child asks why he/she has to conform, I state: because I said so, or I am your parent and I want you to |
12 |
18.8 |
17 |
26.6 |
10 |
15.6 |
13 |
20.3 |
12 |
18.8 |
|
6. I spank when our child is disobedient |
10 |
15.6 |
30 |
46.9 |
13 |
20.3 |
11 |
17.2 |
0 |
0 |
|
10. I punish by taking privileges away from our child with little if any Explanations |
10 |
15.6 |
17 |
26.6 |
10 |
15.6 |
16 |
25 |
11 |
17.2 |
|
13. I yell or shout when our child misbehaves |
9 |
14.1 |
26 |
40.6 |
9 |
14.1 |
16 |
25 |
4 |
6.3 |
|
16. I explode in anger towards our child |
13 |
20.3 |
28 |
43.8 |
14 |
21.9 |
8 |
12.5 |
1 |
1.6 |
|
19. I grab our child when being disobedient |
18 |
28.1 |
17 |
26.6 |
13 |
20.3 |
13 |
20.3 |
3 |
4.7 |
|
23. I scold and criticize to make our child improve |
14 |
21.9 |
17 |
26.6 |
8 |
12.5 |
14 |
21.9 |
11 |
17.2 |
|
26. I use threats as punishment with little or no justification |
42 |
65.6 |
14 |
21.9 |
7 |
10.9 |
1 |
1.6 |
0 |
0 |
|
28. I punish by putting our child off somewhere alone with little if any explanations |
42 |
65.6 |
3 |
4.7 |
9 |
14.1 |
10 |
15.6 |
0 |
0 |
|
30.I scold or criticize when our child’s behavior doesn’t meet our Expectations |
10 |
15.6 |
23 |
35.9 |
8 |
12.5 |
10 |
15.6 |
13 |
20.3 |
|
32. I slap our child when the child misbehaves |
27 |
42.2 |
16 |
25 |
19 |
29.7 |
2 |
3.1 |
0 |
0 |
Table 4. Frequency of responses to the questions regarding the permissive parenting style
|
Question |
Never |
Once in a while |
About half of the time |
Very often |
Always |
|||||
|
N |
% |
N |
% |
N |
% |
N |
% |
N |
% |
|
|
8. I find it difficult to discipline our child |
6 |
9.4 |
19 |
29.7 |
19 |
29.7 |
18 |
28.1 |
2 |
3.1 |
|
15. I give into our child when the child causes a commotion about something |
26 |
40.6 |
11 |
17.2 |
13 |
20.3 |
10 |
15.6 |
4 |
6.3 |
|
17. I threaten our child with punishment more often than actually giving it |
14 |
21.9 |
24 |
37.5 |
5 |
7.8 |
12 |
18.8 |
9 |
14.1 |
|
20. I state punishments to our child and does not actually do them |
9 |
14.1 |
23 |
35.9 |
12 |
18.8 |
11 |
17.2 |
9 |
14.1 |
|
24. I spoil our child |
26 |
40.6 |
14 |
21.9 |
9 |
14.1 |
10 |
15.6 |
5 |
7.8 |
Table 5. Acceptance of each behavioral management technique by the parents
|
Variable |
Percentage (%) |
||||
|
Totally disagree |
Disagree |
No opinion |
Agree |
Totally agree |
|
|
Cooperative children |
|
|
|
|
|
|
Positive reinforcement |
0 |
0 |
1.6 |
23.4 |
75 |
|
Tell-show-do |
1.6 |
1.6 |
7.8 |
20.3 |
68.8 |
|
Parent separation |
0 |
10.9 |
20.3 |
25 |
43.8 |
|
Voice control |
0 |
10.9 |
18.8 |
51.6 |
18.8 |
|
Uncooperative children |
|
|
|
|
|
|
General anesthesia |
1.6 |
1.6 |
14.1 |
28.1 |
54.7 |
|
N2O sedation |
1.6 |
0 |
15.6 |
29.7 |
53.1 |
|
Active restraint |
3.1 |
14.1 |
29.7 |
32.8 |
20.3 |
|
Passive restraint |
20.3 |
23.4 |
17.2 |
26.6 |
12.5 |
Table 6. Correlation of parenting style with parental acceptance of different behavioral management techniques
|
Technique |
Authoritative |
Authoritarian |
Permissive |
|||
|
p-value |
Spearman’s rho |
p-value |
Spearman’s rho |
p-value |
Spearman’s rho |
|
|
Tell-show-do |
0.004 |
+0.35 |
0.001 |
-0.39 |
0.002 |
+0.38 |
|
Positive reinforcement |
0.25 |
+0.14 |
0.089 |
-0.021 |
>0.01 |
+0.3 |
|
Voice control |
0.60 |
+0.06 |
>0.001 |
+0.54 |
0.04 |
-0.25 |
|
Parent separation |
0.003 |
+0.36 |
>0.001 |
-0.59 |
>0.001 |
+0.44 |
|
Active restraint |
0.87 |
-0.02 |
>0.001 |
+0.52 |
>0.001 |
-0.47 |
|
Passive restraint |
0.36 |
-0.11 |
>0.001 |
+0.46 |
>0.001 |
-0.55 |
|
N2O sedation |
0.003 |
-0.36 |
o.09 |
+0.21 |
0.49 |
+0.08 |
|
General anesthesia |
0.01 |
-0.31 |
0.03 |
+0.27 |
0.42 |
+0.1 |
Discussion
This study assessed the relationship of the parenting style with parental acceptance of the behavioral management techniques for pediatric dental patients. The results showed that the acceptance level of the parents of the behavioral management techniques for cooperative and uncooperative children depended on their parenting style. Thus, the null hypothesis of the study was rejected.
The present results showed that positive reinforcement and the TSD technique were the most accepted techniques by the parents for cooperative children. Noninvasiveness and adherence to ethical standards are among the main reasons for high level of acceptance of these techniques. General anesthesia and N2O sedation were the most accepted techniques by the parents for uncooperative children, which can be due to the enhanced knowledge of the parents about these techniques in the recent years. Also, the voice control technique was the least accepted technique for cooperative children, and passive restraint was the least accepted technique for uncooperative children. Taran et al (11) evaluated the association of parenting style and acceptance of behavioral control techniques. The techniques evaluated in their study were similar to those assessed in the current study, except that active restraint and level of cooperativeness of the child were not evaluated in their study. In line with the present findings, they reported that positive reinforcement and the TSD were the most accepted techniques; while, passive restraint was the least accepted technique (11). Also, Veloso et al (25) compared the acceptance level of the parents of the basic and advanced behavioral management techniques and reported that the basic techniques were the most accepted techniques; however, under emergency conditions and when necessary, a significant difference existed in the acceptance level of general anesthesia and N2O sedation compared with other techniques.
With respect to the frequency of different parenting styles, the present results showed significantly higher frequency of the authoritative style, followed by the authoritarian and then the permissive style. However, it should be noted that this result may be influenced by the social desirability bias. Also, fear of being judged may affect the responses of the parents regarding their parenting style. These biases are the inherent shortcomings of the PSDQ; nonetheless, PSDQ is currently the most commonly used instrument for evaluation of parenting style (25-28). To overcome these shortcomings, the questionnaires were filled out by the parents anonymously. Also, each parent watched the video alone (and not with other parents), which further helped minimize bias (29). The frequency of the parenting styles in the present study was similar to that reported by Taran et al (11), Juneja and Aleem (30), and El-Mahdy et al (31). Despite the higher frequency of the authoritative parenting style in the present study and some previous investigations (11,30), it should be noted that since the children of authoritarian and permissive parents usually have a higher rate of dental caries (22,23), this frequency may be totally different among dental patients.
The present results indicated a significant association between the parenting style and acceptance of behavioral management techniques. The authoritative parenting style had a significant positive correlation with acceptance of the TSD and parent separation techniques and a significant inverse correlation with acceptance of general anesthesia and N2O sedation. The authoritarian parenting style had a significant positive correlation with the acceptance of the voice control, active and passive restraint, and general anesthesia, and a significant inverse correlation with the acceptance of the TSD and parent separation. The permissive parenting style had a significant inverse correlation with the acceptance of voice control, and active and passive restraint, and a significant positive correlation with the acceptance of TSD, positive reinforcement, and parent separation. Considering the high level of responsiveness and low level of control by these parents, their lack of interest in techniques that limit the children is understandable.
The present results were in contrast to those of Cerrón Vásquez and Meza Pucuhuayla (29) who found no significant correlation between the parenting style and acceptance of behavioral management techniques, which may be due to the fact that they evaluated 5-11 year-old children, and having a previous dental visit was not among their exclusion criteria. It has been demonstrated that the parenting style has the greatest impact on the behavior of preschool children (11). In agreement with the present results, Taran et al (11) showed that authoritative parents preferred basic techniques to advanced techniques, and were less interested in general anesthesia and N2O sedation for their children. Shalini et al (26) demonstrated that authoritative parents had a more positive impact on the behavior of their children and their children often showed a more positive behavior in dental office. Such parents are less interested in advanced techniques such as general anesthesia and N2O sedation because they believe that these techniques are not necessary for children with high level of cooperation and a positive behavior (11). Similarly, Ortells et al (32) demonstrated that authoritative parents often rejected advanced techniques or accepted them with high level of caution.
The authoritarian parenting style is characterized by high level of control and low level of intimacy and support. Children of such parents are more interested to show dissatisfaction, isolation, and distrust (32). The interest of the authoritarian parents in voice control, active and passive restraint, and general anesthesia can be due to the high level of control and limitation in these techniques, compared with other techniques (11). Unlike the present results, Ortells et al (32) reported that permissive parents accepted general anesthesia and sedation, and even insisted on their implementation, since they believed that these techniques are safer and easier for their children, and they preferred to avoid an unpleasant situation by selecting these techniques. Cultural and social differences among different study populations can explain variations in the reported results. Also, the frequency of permissive parenting style was relatively low in the present study, which might have affected the results, and different results may be obtained in future studies with a larger sample size and higher frequency of this parenting style.
Lack of interest of some parents in watching the video and filling out the questionnaire and poor cooperation of children while the parents were watching the video were the main limitations of this study, which resulted in a relatively small (although statistically sufficient) sample size.
Future studies with a larger sample size are required to take into account the parenting style of both parents.
Conclusion
Parenting style had a significant effect on parental acceptance of behavioral management techniques, and should be taken into account in selection of behavioral management techniques for pediatric dental patients.
Acknowledgement
The authors would like to thank the participating parents for their cooperation. This study was approved by the Ethics Committee of Tehran University of Medical Sciences (Ethics code: IR.TUMS.DENTISTRY.REC.1403.004).
Conflict of Interest
Authors declare no conflict of interest.
