Citation for published version (APA): ten Berge, M. (2001). Dental fear in children: prevalence, etiology and risk factors

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1 UvA-DARE (Digital Academic Repository) Dental fear in children: prevalence, etiology and risk factors ten Berge, M. Link to publication Citation for published version (APA): ten Berge, M. (2001). Dental fear in children: prevalence, etiology and risk factors General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 30 Jan 2019

2 CHAPTERCHAPTER 3,3 THEE DENTAL SUBSCALE OF THE CHILDREN'SS FEAR SURVEY SCHEDULE (CFSS-DS): VALIDITYY AND CLINICAL UTILITY^ Abstract t Thee aim of this study was to report on the reliability and validity of the Dutch parent's versionn of the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) and to studyy its clinical utility. Parents of 718 children between 4 and 12 years of age completed thiss Dutch version of the CFSS-DS on behalf of their child, before or during treatment. In addition,, the dentist treating the child rated its level of dental fear during treatment on a 5- pointt Likert scale from 1) "not afraid at all" to 5) "very afraid". Reliability analysis was performedd and correlation coefficients between the two measures were calculated. The reliabilityy of the scale proved to be high: Cronbach's a was Also, significant correlation coefficientss between the CFSS-DS and the dentist's ratings were found (r=0.58 and r=0.68 respectively,, p<.01), providing support for the validity of the scale. It was concluded that thee CFSS-DS can be of clinical value as a screening device while its predictive value of behaviourr management problems should not be overestimated. 11 This part of this chapter has been submitted for publication as: Berge ten, M., Veerkamp, J.S.J.,, & Hoogstraten, J. The Dental Subscale of the Children's Fear Survey Schedule (CFSS- DS):: validity and clinical utility.

3 ChapterChapter 3.3 Introduction n Thee Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) was developed to assesss dental fear in children. It is a shorter, revised form of the Fear Survey Schedule for Childrenn (FSS-FC), constructed to obtain a specific dental fear questionnaire for children (Cuthbertt & Melamed, 1982; Scherer & Nakamura, 1968). The scale consists of fifteen items withh a 5-point response scale, related to various aspects of dental treatment such as invasive proceduress as injections and drilling, but also to more general medical aspects. This CFSS- DSS has been widely used in recent studies and has been indicated to be a valuable and adequatee measure of dental fear in children. In a review of self-report measurements, it was recommendedd over other measures (Venham Picture Test; Venham, Bengston & Cipes, 1977; Dentall Anxiety Scale; Corah, 1969) with respect to information on its psychometric propertiess (Aartman, Van Everdingen, Hoogstraten & Schuurs, 1998). Prevalence estimates havee been reported for US, Finnish, Swedish, Singaporean and Chinese populations, and cut-offf scores for high dental fear have been set at scores between 38 and 42 (Alvesalo, Murtomaa,, Milgrom, Honkanen, Karjalainen & Tay, 1993; Chellappah, Vignesha, Milgrom && Lo, 1990; Cuthbert & Melamed, 1982; Klingberg, 1994; Klingberg, Berggren & Noren, 1994; Milgrom,, Jie, Yang & Tay, 1994; Milgrom, Mancl, King & Weinstein, 1995). Research in severall countries demonstrated the scale to have good reliability. Both the internal consistencyy and the test-retest reliability proved satisfactory (see Aartman et al., 1998; Alvesaloo et al., 1993; Klingberg, 1994). The CFSS-DS also showed acceptable validity. Significantt relations (ranging from r=0.22 to r=0.87) with constructs such as behavioural ratings,, a physiological measure and other fear questionnaires have been reported (see Aartmann et al., 1998; Klingberg et al., 1994; Klingberg, Vannas Löfqvist & Hwang, 1995a; Melamed,, Yurcheson, Fleece, Hutcherson & Hawes, 1978; Milgrom et al., 1994). It should howeverr be noted that in some of these studies shorter, 8-item versions of the CFSS-DS were usedd and that the size of reported correlations often can be considered moderate or even low.. In some of these studies, a parental version of the CFSS-DS has been used, which was foundd to adequately reflect the children's level of dental fear (Klingberg et al., 1994; Milgromm et al., 1994). Thee aim of the present study was to assess the reliability and validity of the Dutch parent'ss version of the CFSS-DS (Ten Berge, Hoogstraten, Veerkamp & Prins, 1998). In addition,, its predictive value as a screening instrument for dental fear and associated problemss in daily practice was examined. For this purpose, the CFSS-DS was associated withh another measure of child dental fear, in this case the dentist's rating of the child's dentall fear during dental treatment. With respect to this clinical utility, the nature of possiblee discrepancies between the two measures is of importance; in order to accept the 60 0

4 CFS5-DS:CFS5-DS: validity and clinical u CFSS-DSS as an adequate screening instrument and with respect to the prevention of dental fear,, its negative predictive value should be high, thus correctly identifying non- or low fearfull children. In addition, for the dentist treating the child the risk of underestimation of dentall fear should be relatively small, to subsequently render treatment most effective. Therefore,, the correlation between the two measures was studied, and possible discrepanciess were examined more closely by calculating the positive and negative predictivee value of the CFSS-DS (Brunette, 1996). Materiall and methods Participants Participants Thee study population consisted of 718 children (356 girls) treated by one of two dentists (n=5199 and n=199) in two dental practices in the Netherlands. These practices were selected becausee of the large proportion of child dental patients visiting these practices and because bothh dentists did have several years of experience in treating children, so that individual differencess were excluded as much as possible. All children were between 4 and 12 years of age;; their mean age was 7.1 years (SD 2.1). A Dutch two-way translation of the CFSS-DS was made,, and to enable comparisons between the different age levels, the Dutch parent's versionn of the CFSS-DS was used (Ten Berge et al., 1998). The parents of all children were askedd to complete the CFSS-DS on behalf of their child, during or before their child's dental treatment.. Measures Measures Thee CFSS-DS consists of 15 items to be answered on a 5-point scale from 1) "not afraid at all"" to 5) "very afraid". Total scores thus range from 15 to 75. Parents have been found to be welll able to assess their child's level of dental fear by using the CFSS-DS (Klingberg et al., 1994;; Milgrom et al., 1994). Previous research has indicated the following cut-off scores and classificationn of scores for Dutch children: a "non-clinical range" (scores below 32), a "borderlinee range" (scores between 32 and 39) and a "clinical range" (scores of 39 and higher)) (Ten Berge, Veerkamp, Hoogstraten & Prins, in press). Children scoring in the "nonclinicall range" generally are non- or low fearful, and are expected not to cause problems duringg treatment. Children scoring in the "borderline range" may either be at risk of becomingg fearful or possibly already suffer from some degree of dental fear, but their behaviourr may also depend on other factors such as circumstances or temperament. Childrenn scoring in the "clinical range" are considered to be high fearful, and regular treatmentt is often interfered with. 61 1

5 ChapterChapter 3.3 Alll parents were well informed on the purpose of the study and they all signed a consent form.. In addition, the two dentists were asked to rate the child's fearful behaviour during thee child's visit on a 5-point Likert scale ranging from 1) "not afraid at all" to 5) "very afraid"" (Milgrom, Fiset, Melnick & Weinstein, 1988). The dentists were unaware of the parents'' CFSS-DS scores. DataData analysis Reliabilityy analysis was performed to assess the internal consistency of the CFSS-DS. Correlationn coefficients were calculated between the dentist's ratings and the total CFSS-DS scores.. In addition, to assess the clinical utility of the CFSS-DS, the proportion of falsenegativee and false-positive results was studied. Also, to gain information on its clinical value,, positive (PPV) and negative (NPV) predictive values of the CFSS-DS were calculated (Brunette,, 1996). The positive predictive value (PPV=TP/(TP+FP) indicates the proportion of childrenn that has correctly been identified as being fearful, while the negative predictive valuee (NPV=TN/(FN+TN) indicates the proportion of children correctly identified as not beingg fearful. In the present study, these values reflect the proportion of children rated as fearfull or not by the dentists, in other words as showing their dental fear or causing behaviourr management problems or not. Calculations were done using the borderline cutofff score of 32, and were repeated using the clinical cut-off score of 39. Results s Thee mean CFSS-DS score of the study population was 24.7 (SD 9.1). Girls were found to be somewhatt more fearful than boys (25.5 versus 23.9, t=2.37, p=.018), but no age effect was foundd (r=-0.06, p>.05). The internal consistency of the CFSS-DS was high: Cronbach's alpha wass Between the CFSS-DS scores and the dentist's ratings significant correlation coefficientss were found for both dentists (r=0.58, n=519 and r=0.68, n=199, p=.000). Correlationss between the CFSS-DS and the dentist's rating for the different age levels separatelyy showed a declining trend in the strength of the association, ranging from r=0.65 (p<.01,, at 4 years of age) to r=0.41 (p>.05, at 11 years of age). Tablee 1 shows the dichotomised scores on the CFSS-DS and the dentist's ratings. Based onn an earlier study (Ten Berge et al., in press) for the CFSS-DS scores 32 was used as cut-off point,, and for the dentist's ratings scores below 3 were defined as low fearful and ratings of 33 and higher as fearful. According to the CFSS-DS cut-off point, 17.0 % of the children suffer fromm some degree of dental fear (borderline range and higher) versus 10.2 % according to thee dentist's ratings. Of all children in this study, 10 % were considered as fearful by the CFSS-DS,, while the dentist rated them as non-fearful. On the other hand, 3 % of all children 62 2

6 CFSS-DS:CFSS-DS: validity and clinical utility weree considered as non-fearful by the CFSS-DS, but as fearful by the dentist. The positive predictivee value of the CFSS-DS proved to be 0.41 and its negative predictive value Tablee 1. Frequency distribution and percentages of dentist's ratings inn relation to CFSS-DS scores (cut-off score 32), CFSS-DSS dentist's rating loww high total loww TN: 573 (79.8%) FN: 23 (3.2%) 596 (83%) highh FP: 72(10.0%) TP: 50(7.0%) 122(17%) totall 645(90%) 73(10%) 718(100%) NPV:TN/(FN+TN)= PPV:: TP/(TP+FP) =0.41 Inn addition, Table 2 shows the frequency distribution using a cut-off score of 39 for the CFSS-DS.. According to this CFSS-DS cut-off point, 7.4 % of the children suffer from a high levell of dental fear versus 10.2 % according to the dentist. The positive predictive value is and its negative predictive value Tablee 2. Frequency distribution and percentages of dentist's ratings inn relation to CFSS-DS scores (cut-off score 39). CFSS-DSS dentist's rating low w high h total l loww high TN:: 622 (86.6%) FN: 43 (6.0%) FP:: 23 (3.2%) TP: 30(4.2%) 6455 (89.8%) 73 (10.2%) total l 6655 (92.6%) 533 (7.4%) 7188 (100%) NPV:: TN/(FN+TN) = 0.94 PPV:: TP/(TP+FP) = 0.57 Discussion n Thee results of the present study again have demonstrated the reliability of the Dutch parent'ss version of the CFSS-DS to be high. Support for the validity of the scale also was provided.. A significant relation between the CFSS-DS scores and the dentist's ratings was found,, despite the fact that the dentists may have based their rating on more or other aspectss than dental fear. In other words, in the dentist's ratings, which may be mostly based onn the child's actual behaviour during treatment, also aspects such as coping abilities and 63 3

7 ChapterChapter 3.3 temperamentall factors may have been incorporated. The actual behaviour displayed during treatmentt can be seen as the combined outcome of the child's dental fear, its temperament andd its ability to cope with invasive situations (see also Veerkamp, 1994). Of course, it shouldd be noted that this behaviour also depends on the nature or invasiveness of the dental visitt that was rated by the dentist. These notes may explain the fact that the correlation foundd between the CFSS-DS and the dentist's behavioural rating was significant though somewhatt moderate, similar to that found in a previous study (Klingberg, 1994). As indicatedd by Klingberg, Berggren, Carlsson & Noren (1995b), dental fear is not always revealedd as uncooperativeness, and not all children displaying behaviour management problemss are dentally fearful. This notion was also supported by the interesting declining trendd in strength of associations between the two measures with increasing age, indicating thatt for younger children behaviour and dental fear are most strongly connected (LeBaron & Zeltzer,, 1984; Mekarski & Richardson, 1997). This relation weakens as children grow older, possiblyy due to increasing coping abilities and a subsequent change in the expression of fear (Brown,, O'Keeffe, Sanders & Baker, 1986; Prins, 1994; see Winer, 1982). Forr the clinical utility of the CFSS-DS it is of interest to specifically consider the nature of thee discrepancies between measures. That is, an overestimation of dental fear by the CFSS- DSS would be preferred over an underestimation when using the CFSS-DS as a screening instrumentt prior to treatment. For effective dental treatment, only the latter could have a negativee effect on the child, while the former may cause the dentist to be extra careful, whichh would influence treatment in a positive way. In the present study for ten percent of alll children this overestimation was found, while for only three percent of all children dental fearr was potentially underestimated. Furthermore, its high negative predictive value (0.96) impliess that in case of the CFSS-DS indicating no or low fear, the likelihood of children actingg out or behaving very fearful is small. Its relatively low positive predictive value (0.41),, however, seems to confirm the notion that not all fearful children show their fear or displayy management problems, as discussed before. A substantial part of the fearful childrenn seems to have not acted out, given that the dentist did perceive them as low or nonfearful,, and for this group extra caution is needed. A difference clearly exists between dental fearr and actual fearful behaviour in children, leading to important clinical implications. That is,, in daily practice it is highly important to be alert on children possibly suffering some degreee of dental fear but not showing their fear, or children at risk of developing fear. This groupp of children may seem to experience no difficulties during treatment, while they essentiallyy may have problems accepting or coping with the situation. The development of dentall fear may be prevented or stopped by providing extra attention and a proper behaviourall management approach for these children, as children may thus be guided 64 4

8 CFSS-DS:CFSS-DS: validity and clinical utility towardss a more adequate coping style. In conclusion, the clinical value of the CFSS-DS as a screeningg device of dental fear in daily practice is supported, while its value as a predictor of behaviourall management problems should not be overrated. Even when using the clinical cut-offf score of the CFSS-DS, over 40% of these high fearful children did not behave fearful inn the dentist's perception. Besidee as a screening tool in daily practice, the CFSS-DS can be used as an indicator for thee need of referral to a centre for special dental care. Additional assessment of concomitant problemss may however be necessary at these centres to further verify the reason for referral. Informationn on such problems may be helpful in further discriminating actual fear and behaviourall management problems. Children may essentially have other problems such as behaviourall disorders interfering with dental treatment, or on the other hand, high dental fearr may be masked by a child's general shyness or internalising coping style (Klingberg & Broberg,, 1998; Ten Berge, Veerkamp, Hoogstraten & Prins, 1999). Based on this information onn dental fear and on possible other problems, the proper management strategy for subgroupss of children can be selected, subsequently increasing the chances of effective treatment

9 ChapterChapter 3.3 References s Aartman,, I.H.A., Everdingen van, T., Hoogstraten, J., & Schuurs, A.H.B. (1998). Self-report measurementss of dental anxiety and fear in children: a critical assessment. ASDC Journal of DentistryDentistry for Children, 65, Alvesalo,, I., Murtomaa, H., Milgrom, P., Honkanen, A., Karjalainen, M., & Tay, K.M. (1993). Thee Dental Fear Survey Schedule: a study with Finnish children. International Journal of PaediatricPaediatric Dentistry, 3, Bergee ten, M., Hoogstraten, J., Veerkamp, J.S.J., & Prins, P.J.M. (1998) The Dental Subscale of thee Children's Fear Survey Schedule: a factor analytic study in the Netherlands. Community DentistryDentistry and Oral Epidemiology, 26, Bergee ten, M., Veerkamp, J.S.J., Hoogstraten, J., & Prins, P.J.M. (1999). Behavioural and emotionall problems in children referred to a Centre for Special Dental Care. Community DentistryDentistry and Oral Epidemiology, 27, Bergee ten, M., Veerkamp, J.S.J., Hoogstraten, J., & Prins, P.J.M, (in press). Childhood dental fearr in the Netherlands: prevalence and normative data. Community Dentistry and Oral Epidemiology. Epidemiology. Brown,, J.M., O'Keeffe, J., Sanders, S.H., & Baker, B. (1986). Developmental changes in children'ss cognition to stressful and painful situations. Journal of Pediatric Psychology, 11, Brunette,, D.M. (1996). Critical thinking. Understanding and evaluating dental research. Carol Stream:: Quintessence Publishing. Chellappah,, N.K., Vignesha, H., Milgrom, P., & Lo, G.L. (1990). Prevalence of dental anxiety andd fear in children in Singapore. Community Dentistry and Oral Epidemiology, 18, Cuthbert,, M.I. & Melamed, B.G. (1982). A screening device: children at risk for dental fears andd management problems. ASDC Journal of Dentistry for Children, 49, Klingberg,, G. (1994). Reliability and validity of the Swedish version of the Dental Subscale off the Children's Fear Survey Schedule, CFSS-DS. Acta Odontologica Scandinavica, 52, Klingberg,, G., Berggren, U., Carlsson, S.G., & Noren, J.G. (1995b). Child dental fear: cause relatedd factors and clinical effects. European Journal of Oral Sciences, 103, Klingberg,, G v Berggren, U., & Noren, J.G. (1994). Dental fear in an urban Swedish population:: prevalence and concomitant factors. Community Dental Health, 11, Klingberg,, G. & Broberg, A.G. (1998). Temperament and child dental fear. Pediatric Dentistry, 20,20, Klingberg,, G., Vannas Löfqvist, L., & Hwang, C.P. (1995a). Validity of the Children's Dental Fearr Picture test (CDFP). European Journal of Oral Sciences, 103, LeBaron,, S. & Zeltzer, L. (1984). Assessment of acute pain and anxiety in children and adolescentss by self-reports, observer reports and a behavior checklist. Journal of Consulting andand Clinical Psychology, 52, Mekarski,, J.E. & Richardson, B.A. (1997). Towards convergent validation of children's dental anxietyy and disruptiveness ratings. Perceptual and Motor Skills, 85,

10 CFSS-DS:CFSS-DS: validity and clinical utility Melamed,, B.G., Yurcheson, R., Fleece, E.L., Hutcherson, S., & Hawes, R. (1978). Effects of filmedd modeling on the reduction of anxiety-related behaviors in individuals varying in levell of previous experience in the stress situation. Journal of Consulting and Clinical Psychology,Psychology, 46, Milgrom,, P., Fiset, L., Melnick, S., & Weinstein, P. (1988). The prevalence and practice managementt consequences of dental fear in a major US city. Journal of the American Dental Association,Association, 116, Milgrom,, P., Jie, Z. Yang, Z., & Tay, K.M. (1994). Cross-cultural validity of a parent's versionn of the Dental Fear Survey Schedule for Children in Chinese. Behaviour Research and Therapy,Therapy, 32, Milgrom,, P., Mancl, L., King, B., & Weinstein, P. (1995). Origins of childhood dental fear. BehaviourBehaviour Research and Therapy, 33, Prins,, P.J.M. (1994). Anxiety in medical settings. In T.H. Ollendick, N.J. King & W. Yule (Eds.),, Handbook of phobic and anxiety disorders in children and adolescents: issues in clinical childchild psychology (p ). New York: Plenum Press. Scherer,, M.W. & Nakamura, C.Y. (1968). A Fear Survey Schedule for Children (FSS-FC): a factorr analytic comparison with manifest anxiety. Behaviour Research and Therapy, 6, Veerkamp,, J.S.J. (1994). Nitrous oxide, happy air or hot air? PhD Thesis. University of Amsterdam,, Amsterdam. Venham,, L.L., Bengston, D., & Cipes, M. (1977). Children's responses to sequential dental visits.. Journal of Dental Research, 56, Winer,, G.A. (1982). A review and analysis of children's fearful behavior in dental settings. ChildChild Development, 53,

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