Attitudes of Hispanic parents toward behavior ...

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Attitudes of Hispanic parents toward behavior management techniques Stuart Scott, DDS Franklin Garcia-Godoy, DDS, MS

T

.rearing children in a pediatric dental practice often Are involves the use of behavior management techniques. Some of these techniques may require physical restraint or general anesthesia, and some are considered controversial and objectionable by dentists and parents.1 Although consent should be obtained from the parents before using such techniques, for parents to consent knowingly, they must understand the procedure and its purpose.2 Parental acceptance of the techniques used in pediatric dentistry have been studied only scarcely in different populations.37 In studies conducted with white parents, the results showed that pharmacological techniques, hand-over-mouth, and restraint were rated as unacceptable by the majority of parents.3"5 No study has reported the attitudes of Hispanic parents toward behavior management techniques used in pediatric dentistry.

Acknowledgment: To Dr. Dennis McTigue for providing the videotapes used in this study and for his constructive comments. Dr. Scott was a pediatric dentistry resident at the University of Texas Health Science Center at San Antonio, San Antonio, Texas. At present he is in private practice, Springfield, Missouri. Dr. Garcia-Godoy is Professor, Departments of Pediatric Dentistry, Restorative Dentistry, and Pediatrics (Medical School), University of Texas Health Science Center at San Antonio, San Antonio, Texas. This paper was presented by Dr. Scott in partial fulfillment of the requirements for the Certificate in Pediatric Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, Texas.

The purpose of this study was to determine the attitudes of Hispanic parents toward behavior management techniques commonly used in pediatric dentistry. MATERIALS AND METHODS

Thirty-two parents of pediatric patients presenting for dental treatment were selected at random from the Department of Pediatric Dentistry at the University of Texas Health Science Center at San Antonio. A standardized experimental description was read to the parents by one dentist to explain the purpose of the study. Written consent to participate in the study was obtained from each parent before beginning the survey. Information about the parents was collected via a questionnaire. The information collected included: age, sex, marital status, completed level of education, total family income, frequency of dental visits, previous bad experiences in a dental office, age they believe a child should first visit the dentist, the reason for today's visit, forms of discipline used at home, and their current personal stress level. The information was used to determine any significant difference that could be related to the acceptability of the behavior management techniques used. The subjects viewed one of two videotapes with a recorded program demonstrating eight different behavior-management techniques. The methodology and videotapes were those of Lawrence et al.6 One tape, shown to half the experimental population, included a

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Table 1 CD Behavior management technique groups. Verbal management P h a r in a co 1 ogi c in a n age in e n t

Physical management

1) Tell-Show-Do 2) Voice control 3) Nitrous oxide 4) Oral premedication 5) General anesthesia 6^ Active restraint 7) Hand-Over-Mouth 8) Passive restraint

brief verbal explanation and rationale of the specific behavior management technique before its demonstration (Group A, ten minutes in length). The other tape, shown to the remaining half of the population, had no explanation before the demonstration of the technique (Group B, 8.5 minutes in length). Each demonstration of a technique, which lasted from twenty to sixty seconds, showed how the technique was used to gain cooperation from a three-to-five-year-old pediatric dental patient. The eight behavior management techniques are shown in Table 1. Following each segment of the tape, time was allotted (ten seconds) for the subjects to indicate their degree of acceptability of the technique, using a visual analogue scale (VAS).8 On the VAS, a mark at the left end of the scale (measuring one millimeter in length from the left anchor on a horizontal line) implied that the behavior management technique being studied was completely acceptable, while a mark on the far right end of the horizontal line (measured at 99 mm) implied that the technique was completely unacceptable. Between these two end points were successive degrees of acceptance to unacceptance. Thus, scores less than 50 were considered acceptable, while those greater than 50 were considered unacceptable. Data analysis was performed, using an F-test (0.05 level) and Pearson and Spearman correlation tests. RESULTS

No significant correlations were found within or between Groups A and B (Explanation and No Explanation, respectively) for any demographic or stress-level factors. Eighty-one percent of the study population (n = 32) had completed at least a high school education. Fifty-six percent of Group B had some post-secondary education versus 25 percent for Group A. For both Groups A and B, 81 percent of the responding parents were female. The mean age of Group A parents was 32.6 years, while Group B was 36.0 years. Eighty-one percent of both groups were currently married. The study population came from mainly lower to middle class families (Table 2).

Table 2 CD Distribution of sociodemographic variables for experimental groups.

Variable Mean age (Mean/S.D.) Gender (Male/Female) Income categories $40,000 Marital status (S/M/D) Education level (HS)

Experimental (Explanation)

N - 16

Control (No explanation) N 16

32.6 ± 5.1 3/13

36.0 ± 5.1 3/13

1 3 3 3 4

5 2 2 3 4

1/14/1

1/15/0

3/9/4

3/4/9

Table 3 CD Mean Visual Analogue Score given by technique group (Score given in millimeters). Experimental (Explanation) N - 16 Mean S.E. 20.6 ± 5.0 25.2 ± 6.2 54.3* ± 6.3

Variable Verbal Pharmacologic Physical * - Statistically significant (P < 0.05).

Control (No explaualii N 16 Mean S.E. 18.9 ± 3.5 27.8 ± 5.7 57.9* ± 6.3

Table 4 CD Mean Visual Analogue Score for each behavior management technique by experimental group (Score given in millimeters).

Variable

Experimental (Explanation) l\ - 16 Mean S.E.

7.5 ±2.9 Tell-Show-Do 33.7 ± 8.4 Voice control 24.6 ±7.4 Nitrous oxide 21.7 ±7.5 Oral premedication 29.4 ±8.8 General anesthesia 28.8 ±6.5 Active restraint Hand-Over-Mouth 63.7* ±9.8 Papoose board 70.4* ±8.7 Statistically significant (P < 0.05).

Control (No explanation) N 16 Mean S.E. 15.5 22.3 19.2 30.5 33.8 37.7 75.4* 60.6*

± 5.2 ±6.1 ±6.7 ±8.6 ±8.3 ±9.2 ±7.6 ±9.1

None of the behavior management techniques included in the study received complete acceptance from all the parents in any of the study groups. Although verbal management techniques were more acceptable than pharmacologic techniques, the differences were not significant. Physical management techniques were significantly less acceptable to parents, however, than either verbal or pharmacologic means (P < 0.05). There were no significant differences between Groups A and B for any behavior management technique. Mean VAS scores are shown in Table 3. Results from the Mean VAS scores by experimental group are shown in Table 4. Results of hand-over-mouth (HOM) and papoose board (PB) techniques were statistically significantly different (P < 0.05) in showing greater disapproval from all other techniques in the study. Both groups, as indicated by parental scores, would rather have the child subjected to general anesthesia than HOM. Results showed that HOM was

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Table 5 O Mean Visual Analogue Score by age group (Score given in millimeters) (n - 32). Behavior Management Technique Less than 35 years 6.7 Tell-Show-Do Voice control 36.6 Nitrous oxide 20.8 Oral premedication 29.9 Ceneral anesthesia 42.4 Active restraint 39.9 75.5* Hai ld-Over-Mou th 75.5* Papoose board * = Statistically significant (P < 0.05).

35 years or older 16.3 19.4 22.9 22.3 20.8 26.5 63.6* 55.5*

unacceptable by 63 percent of the parents in Group A and 81 percent in Group B. The PB technique was unacceptable in 81 percent in Group A and 63 percent in Group B. No statistically significant differences were noted between the control and experimental groups for any technique. There were no significant differences in VAS scores between parents from the two age-groups. These groups followed the previously mentioned data that HOM and PB were statistically significantly less acceptable than the other behavior management techniques (Table 5). DISCUSSION This study explored the attitudes of Hispanic parents toward behavior management techniques used in pediatric dentistry. Parents were recruited from the waiting room for the Pediatric Dentistry Clinic. Eighty-one percent of the parents had at least a high school education. The parents were from lower to middle socioeconomic classes. As stated by Havelka, however, "Social status seems to be only a factor in determining parent's acceptance of behavior management techniques."7 The VAS was developed to allow some forms of nonparametric data to be expressed in parametric form. The VAS is widely used in behavioral and neurophysiological disciplines. Parents seemed to approve of certain management techniques. Verbal techniques (Tell-show-do and voice control) had the greatest, although not total acceptance. Management techniques with medication (nitrous oxide, oral premedication, general anesthesia) were rated as slightly less acceptable by both Groups A and B than verbal techniques, but not significantly. Physical management techniques (papoose board, hand-over-mouth, active restraint) were shown to be statistically (P < 0.05) the most unacceptable to the parents as compared with verbal and pharmacological means. The dentist perhaps should use this technique hierarchy in the order of the least aversive technique when attempting to gain pa-

rental acceptance. Importantly, the dentist should include the parent in the treatment planning of the child's dental needs. An informed parent is more likely to show greater acceptance of a behavior management technique that the dentist might employ. This agrees with the findings of both Lawrence et al and Frankel.69 Lawrence et al found in his study of eighty parents that individuals viewing the videotapes with explanations were significantly more receptive to behavior management techniques than those viewing the videotapes without explanations. In a 1991 study by Frankel, parental acceptance of the use of a papoose board was investigated.9 His findings suggested that if parents were well informed of the treatment modalities, they might be more likely to agree with the planned treatment for the child and hence avoid further conflicts with the dentist. Inclusion of an explanation does not guarantee, however, acceptance of a technique. In our study we found that no single behavior management technique was rated completely acceptable by all parents in either of the groups. These results differ from those obtained by Lawrence et al.6 This difference may be attributed to the smaller population in our study. Lawrence et al found that none of the management techniques was ever judged as being unacceptable by his experimental group and only by four subjects in the control group.6 A comparison of the parental responses noted by Lawrence et al with those from the current study further emphasizes how individuals differ in what they view as acceptable.6 Dentists must be aware that they cannot treat the child as they wish, in order to complete the child's dental work. The parent must be actively involved with the treatment planning and process. In both groups in this study parents would rather have had their children subjected to general anesthesia than to HOM. Our findings support the conclusion of Havelka that parents from lower socioeconomic levels are more receptive to general anesthesia when presented with options, but become less enthusiastic when the procedure is explained. Of interest in the present study, however, is that the videotape explanation of the behavior management technique for general anesthesia did not include potential complications. If parents had been told of the possibility of death or other untoward reactions, the results comparing these two techniques might have been different. This subject area warrants further investigation. Tell-show-do was the most acceptable by both groups. This is in agreement with the study by Lawrence et al where he also found this method of behavior management to have the greatest acceptance.6 Tell-show-do is

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an accepted technique for the dentist to use with the potentially uncooperative patient. As shown in our study, no techniques were rated as completely acceptable by parents in either group, however, as some parents even objected to this noninvasive, nonintimidating behavior management technique. Hand-over-mouth and papoose board techniques showed the greatest degree of nonacceptance, compared to all the other behavior management techniques in both groups (P < 0.05). This is in agreement with previous studies.3'6 Some parents, as well as some dentists, simply do not want to expose their children to these management techniques. Nathan further explains the aversive techniques.10 From data collected at the National Conference and Workshops on Child Behavior Management at Iowa City, Iowa, 66 percent of the surveyed population of pediatric dentists indicated they used HOM periodically in their office. When the dentists were asked if parents objected, 38 percent found that parents did object to it. In the present study, 63 percent in the experimental group and 81 percent in the control group objected to HOM. If parents see the technique, with or without explanation, they may be less receptive. The papoose board is seen by the dentist to be a valuable tool in the management of the patient who lacks cooperative ability. As shown by Frankel, if the papoose board is explained in the positive sense, parents are more receptive to its use.9 The results of this study contradict those of Frankel.9 Despite an explanation, 81 percent of the parents still found it to be unacceptable. The differences in these results could be due to the small population size of our study or differences in how the procedure was explained by Frankel.9 It remains to be seen what the long-term implications are of HOM or the papoose board; but current thinking of some individuals consider it to be unacceptable. Data trends from this study tended to support the conclusions from some studies and refute those from others. Perhaps due to the small number of subjects involved, statistical significance between groups was not achieved. Had the number of subjects been larger, the results from this study of Hispanic parents may have

mirrored those previous studies of other ethnic groups. This remains to be tested. CONCLUSIONS

Dentists should include the parents in managing the child patient, to please them. With this in mind, the following suggestions are derived from this study. • An informed parent is more likely to show greater acceptance of a behavior management technique. • No techniques are found to be totally acceptable by all parents. • Hand-over-mouth and papoose board showed a statistically greater degree of nonacceptance than all the other behavior management techniques in both groups. • Tell-show-do showed the greatest acceptance by both groups. • Parents would rather have the child subjected to general anesthesia than hand-over-mouth.

REFERENCES 1. American Academy of Pediatric Dentistry: Beltavior management for the pediatric dental patient. Final proceedings of a workshop, September 30-October 2,1988, Iowa City, IA, 1988. 2. Hagan, P.P. et ai. The legal status of informed consent for behavior management techniques in pediatric dentistry. Pediatr Dent, 6:204-208, December 1984. 3. Murphy, M.G.; Fields, H.W.; Machen, J.B.: Parental acceptance of pediatric dentistry behavior management techniques. Pediatr Dent, 6:193-198, December 1984. 4. Weinstein, P. and Nathan, J.E.: The challenge of fearful and phobic children. Dent Clin North Am, 32:667-692, October 1988. 5. Fields, H.W.; Machen, J.B.; Murphy, M.G.: Acceptability of various behavior management techniques relative to the types of dental treatment. Pediatr Dent, 6:199-203, December 1984. 6. Lawrence, S.M.; McTigue, D.J.; Wilson, S. et ai. Parental attitudes toward behavior management techniques used in pediatric dentistry. Pediatr Dent, 13:151-155, May-June 1991. 7. Havelka, C. et al: The influence of social status and prior explanation on parental attitudes toward behavior management techniques. Pediatr Dent, 14: 376-381, November-December 1992. 8. Clark, PR. and Spear, F.G.: Reliability and sensitivity in the selfassessment of well-being. Bull Br Psychol Soc,17:18, January 1964. 9. Frankel, R.I.: The papoose board and mother's attitudes following its use. Pediatr Dent, 13:284-288, September-October 1991. 10. Nathan, J.E.: Management of the difficult child: A survey of pediatric dentists' use of restraints, sedation, and general anesthesia. J Dent Child, 56:293-301, July-August 1989.