|Year : 2009 | Volume
| Issue : 4 | Page : 205-210
Anxiety among adolescents and its affect on orthodontic compliance
G Trakyali1, F Isik-Ozdemir1, T Tunaboylu-Ikiz2, B Pirim2, A Elif Yavuz2
1 Department of Orthodontics, Faculty of Dentistry; Yeditepe University, Istanbul, Turkey
2 Department of Psychology, Faculty of Social Sciences; Istanbul University, Istanbul, Turkey
|Date of Web Publication||14-Nov-2009|
Yeditepe Universitesi Dis Hekimligi Fakültesi, Barbaros Bulvari, Sakir Kesebir Sokak No. 26, Balmumcu-Besiktas 34349 Istanbul
| Abstract|| |
Background: Investigations have suggested that poor compliance could be an indicator of poor relationship with family and could be related to the person's personality traits. Aim: The aim of this study was to determine the effect of parents attitude, the anxiety during treatment and self-confidence/self-care of the patient on cooperation during orthodontic treatment. Materials and Methods: The study material consisted of questionnaires completed by 82 adolescent patients and their parents. The patients were divided into two groups of 42 compliant and 40 non-compliant patients. The above-mentioned questionnaries were State-Trait Anxiety Inventory-STAI, Piers-Harris Children's Self Concept Scale and The Exercise of Self-Care Agency for the patients and Mc Master Family Assessment Device and Parental Attitude Research Instrument-PARI for the parents. Results: The problem solving and caring attitude of the father and his determinative role in the family had a positive infulence on the compliance of the child. The patients who showed better compliance also had a lower state of anxiety, which could also be explained by the positive effect of the attitude of the father in the family. Conclusion: It would be useful to overcome the increased state of anxiety of the child in the orthodontic clinic by using educational and relaxation techniques. Besides, it would be wise to ask the father to be present at the first appointment during part of the education of the child.
Keywords: Anxiety, parent attitude, orthodontic compliance
|How to cite this article:|
Trakyali G, Isik-Ozdemir F, Tunaboylu-Ikiz T, Pirim B, Yavuz A E. Anxiety among adolescents and its affect on orthodontic compliance. J Indian Soc Pedod Prev Dent 2009;27:205-10
|How to cite this URL:|
Trakyali G, Isik-Ozdemir F, Tunaboylu-Ikiz T, Pirim B, Yavuz A E. Anxiety among adolescents and its affect on orthodontic compliance. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2013 Jun 18];27:205-10. Available from: http://www.jisppd.com/text.asp?2009/27/4/205/57654
| Introduction|| |
Even though the need for patient compliance in orthodontics has been minimized in the past, cooperation of the patient during orthodontic treatment is a major determinant of a successful treatment result. Patient compliance is not only limited to appliance wear but it also includes the daily tasks of oral hygiene procedures, proper caring for orthodontic appliances and keeping routine scheduled appointments on time.
It is essential to have a very good patient cooperation in order to reach esthetic goals and to ensure that the patient gets a pleasing result at the end. A patient's non-compliance can result in a longer treatment time, destruction of the teeth and periodontium, extraction of additional teeth, collapse of a corrected malocclusion after treatment, frustration for the patient and additional stress for the orthodontist and staff.  Therefore, it is very important to evaluate the clinical cooperation before the initiation of orthodontic treatment. ,
Investigations have suggested that poor compliance could be an indicator of poor relationship with family and could be related to the person's personality traits.  Similarly, the anxiety traits in children and adolescents have been related to familial attitude. ,, Mild fear and anxiety are expected experiences, consistent with normal development, but they become a concern and potentially in need of treatment when the fear or anxiety is disproportionate to the actual threat and daily functioning becomes impaired. 
Anxiety is defined as a set of behavioral manifestations that can be divided into state and trait anxiety.  State anxiety is a transitory emotional condition that varies in intensity and fluctuates over time whereas trait anxiety is a personality trait that remains relatively stable.  It involves a tendency to be apprehensive and to manifest anxiety even without external stress. The perceived family characteristics may have an effect on the child's anxiety. 
Klima et al.  stated that families seek orthodontic treatment in the hope that the child's appearance will be appropriate for the social and familial ideals in terms of facial esthetics. The most important motivating factor on a child during orthodontic therapy is thought to be the influence of parents' attitude and perception of dental esthetics. , Self-perception of the child and the parents extremely tolerant attitude are reported as the most important factors influencing the child's compliance to treatment. ,
The parents penalizing or awarding approaches also affect the accomplishment of the treatment positively. Pressure inflicted on the child by the parents will force the child to present the right behavior; however, in the absence of the parents compulsive approach, the child will not present the desired attitude.  A lot of research has been performed in the way parents influence the development of anxiety in children that has identified numerous parental factors that may have an impact on child anxiety: modeling, encouragement, overprotection, intrusiveness or control, acceptance, support, rejection, promotion of avoidance, parental interpretation, validation of emotion, expressed emotion, attachment, marital conflict and parental psychopathology as an underlying factor. ,
A recent study on the anxiety levels of orthodontic patients and their parents revealed that the trait anxiety levels of the parents and the state anxiety levels of the patients were high at the beginning of orthodontic treatment; however, the study had not investigated the relationship between the anxiety levels and patient cooperation.  The aim of this research was:
(1) to evaluate the effect of the parents attitude on the child's anxiety level and compliance during orthodontic treatment, (2) to show the relationship between the child's compliance and her/his state of anxiety and (3) to exhibit the effect of the child's self-perception and self-esteem on her/his compliance during treatment.
| Materials and Methods|| |
The material of this institutionally approved study comprised of psychological test forms filled out by adolescent patients and their parents (patients' mother and father). One hundred and sixty-five patients were randomly selected from the active patient list, between ages 10 and 19 years (15.52 ± 3.25), who had both their parents in the household, by the secretary. Patients were selected from the state-funded patients list according to the following criteria: (1) same socioeconomic status, (2) presence of two parents in the household. Patients with single parents were not included in this study. Among these, 125 patients (61 girls and 64 boys) and their parents accepted to participate in this study.
The parents were informed of the purpose of the study, were assured of their right to refuse to participate or withdraw at any stage and anonymity and confidentiality were guaranteed.
Subjects were followed-up for at least 18 months at the Orthodontics clinic. According to the aim of this study, patients received no motivational reinforcement during the observation period. Orthodontic treatment of all patients participating in the study was performed at the same university clinic by the same orthodontist who was not provided in this study. All patients had fixed orthodontic appliances.
Tests were sent to working parents who were not able to visit the clinic via mail or the patient and received back by mail. Thirty-five patients whose parents had not returned the forms, which they were given to fill in, were excluded from the study.
Among 90 patients who participated in the study, 42 compliant and 40 non-compliant patients were assigned to two groups according to the following criteria: (1) properly maintaining oral hygiene, (2) showing up for their regularly scheduled appointments, (3) using orthodontic appliances as instructed by their orthodontist. Good oral hygiene was defined as the patient cleaning the appliances consistently, having minimal presence of gingivitis. Good appliance maintenance and care referred to the absence of broken or distorted appliances, loose bands and/or brackets during treatment period. Good elastic and headgear compliance referred to continuous wear of each item as directed by the orthodontist. Good compliance with regard to missing and/or being late for appointments was judged by the number of absences and lateness' over the period of active treatment. Patients missing their scheduled appointments more than three times or coming late beyond 10 min more than three times were assigned to the non-compliant group. Patients categorized as exhibiting good compliance performed well in all the above areas. Poor compliance meant that the patient was negligent in most areas or in one area to an extent that treatment was significantly compromised. The remaining eight refused to contribute in the study at this stage.
A total of five questionnaires, three for the children and two for the parents, were given to the subjects. Spielberger State-Trait Anxiety Inventory (STAI), Piers-Harris Children's Self Concept Scale (PHS) and The Exercise of Self-Care Agency (ESCA) were given to the patients. Mc Master Family Assessment Device (FAD) and Parental Attitude Research Instrument (PARI) were given to the parents. The Turkish adaptations of the tests were used for the questionnaires given to the subjects.
The STAI was developed by Spielberger et al.  The STAI is a self-report instrument, which is compromised of separate, self-report scales measuring two distinct anxiety concepts: state anxiety (how one feels at a particular moment; e.g. dental visit) and trait anxiety (how one usually fears). The state anxiety score is based on 20 items for which a person rates anxiety on a scale from one (almost never) to four (very much so). The trait anxiety score is composed in a similar fashion with 20 questions designed to measure anxiety. The STAI has been validated for many situations and populations in several studies.  Reliability and validity studies of the STAI were conducted by Φner and Le Compte  after adapting into Turkish.
The PHS is an 80-item questionnaire (answered as yes/no) that is a quantitative self-report measure of childrens' self-esteem.  The PHS was adapted by Φner  for use with Turkish children.
The ESCA was developed by Kearney and Fisher  and was revised according to construct and discriminate validity findings reported by Reish and Hauck.  The aim of this scale is to assess one's ability for self-care, including the areas of self-concept, initiative and self-responsibility, knowledge and information seeking and passivity. The scale consists of 35 items, each scored from zero (very characteristic of me) to four (very uncharacteristic of me). The ESCA was used in a Turkish-adapted version. 
The FAD was developed by Epstein  and is composed of 60 items containing seven subscales with six items for problem solving, nine items for communication, 11 items for roles, six items for affective responsiveness, seven items for affective involvement, nine items for behavioral control and 12 items for general functioning. Rating are performed on a scale from one (a health answer) to four (an unhealthy answer). The Turkish translation and validity study of FAD was conducted by Bulut. 
The PARI was developed by Schafer and Bell.  The scale is a 60-item questionnaire with a four-point answering scale and five subscales: overprotection, democratic quality attitude, rejection of housewife role, parental discord and discipline/oppression dimension. The PARI was adapted into Turkish by LeCompt et al. 
The t-test was used in order to compare the state and trait anxiety conditions of the compliant and non-compliant groups. Linear model analysis was used to compare the parental attitudes of the two groups of the PARI subtests. Furthermore, the Mann-Whitney U analysis was used to evaluate the parental attitude of the two groups from the FAD subtests. Significance for all statistical tests was predetermined at P<0.05.
| Results|| |
The mean state and trait anxiety values and standard deviation for compliant and non-compliant groups are presented in [Table 1].
Comparing the compliant and non-compliant groups from the point of anxiety levels, no statistical difference was found for the trait anxiety (P=0.25, P>0.05), whereas there was a statistically significant difference in state anxiety (P=0.03, P<0.05).
When PARI subtests were evaluated according to the general linear model analysis, no significant differences were observed between the mothers' attitude of compliant and non-compliant groups (P=0.444), and also no statistically significant difference was found between the fathers' attitude of compliant and non-compliant groups; however, more significant than mothers' attitude (P=0.120 ).
Results of the Mann-Whitney U test performed to evaluate data from the Mc Master Family Assessment Device showed that the behavior characteristics of fathers' in the family pointed out to statistically significant differences in three parameters: father's behavior at the problem solving skills (P=0.010, P<0.05), determinative familial roles (P=0.023, P<0.05) and ability to show necessary concern (P=0.001, P<0.01), [Table 2].
The childrens' self-perception and self-esteem scores were evaluated between the cooperating and non-cooperating groups by t-test analysis, which did not reveal any statistically significant differences (P=0.121, P>0.05). Likewise, no significant difference was observed in terms of self-care between the two groups (P=0.223, P>0.05).
| Discussion|| |
This research was built on the hypothesis that compliance and non-compliance of adolescents receiving orthodontic treatment might be explained by their anxiety levels and whether this anxiety level was effected by their parents' attitude. Another hypothesis was that patients' self-care could be effective on the level of the patient compliance. The significantly higher state anxiety levels observed in the non-compliant group could be accepted as an indicator of the effect of state anxiety levels on level of compliance during dental treatment among adolescents. Tests performed by the parents show that father's attitude had an important role on adolescent compliance.
Patients included in this study were all chosen from the state-funded patients list and therefore accepted as being at the same socioeconomic status. Although Folayan et al.  concluded in a previous study that there was no statistically significant association between socioeconomic status of the children and anxiety, in another study, Bedi et al.  pointed out that differences in socioeconomic status may cause different behavioral attitudes that may affect state anxiety and self-esteem among groups.
Fathers have been ignored in research on child anxiety because mothers are thought to be easier to involve in research. 
In this study, the affect of both mother's and father's behavioral attitudes on anxiety levels and cooperation levels was compared. Therefore, patients with single parents or missing forms that should be filled in by one of the parent were excluded from this study.
In previous studies, it has been hypothesized that personality traits might at least partly determine a patient's motivation for orthodontic treatment as well as adherence with health guidelines in general.  Albino et al.  found that variables such as anxiety, self-concept, social desirability and need for achievement do not appear to have a great value in predicting adolescent orthodontic cooperation. Result of this research revealed that the level of trait anxiety did not exhibit any difference between the compliant and non-compliant groups whereas the state anxiety was found to be higher in the non-compliant group. Controversial to the findings of Cohen et al.,  who pointed out that anxiety was found to disturb sleep and to have a profound affect socially, interfering with personal relationship, the findings of the present study indicated that state anxiety existed only during dental treatment and did not have an influence on the patient's daily life.
In a previous study, Rayen et al.  concluded that the extent of anxiety a child experiences did not relate directly to dental knowledge but was found to be an amalgamation of personal experiences, family concerns, disease levels and general personality traits. Similar to the results of Rayen et al.,  in the present study, the parents attitude was found to have a significant role on the child's positive compliance.
In the present research, results indicated that the mothers' attitude toward their children did not have any effect on the child's compliance levels whereas the fathers' attitude played an important role on compliance. Controversially, Lamb  pointed out that mothers spend more time with their children and concluded that they have a greater impact on their children. However, there is no evidence linking the amount of parental involvement with desirable child outcome, suggesting that the quality rather than the quantity of involvement is most influential.  In addition, involvement of the father in raising children has increased.  The father's problem-solving skills, his ability to show the necessary care and his determinative familial role may have reinforced good cooperation habits in the child. The level of state anxiety being low in the compliant group can further be explained by the father's constructive role in the family.
It was observed that the child's perception of her/his family life had an influence on her/his coping with apprehensive situations. The existence of a problem solving, caring and role-defining father reduced the state anxiety in the child thereby promoting the cooperation of the child during treatment.
The results of the present study showed no relation between the patient's self-care scores and her/his compliance during orthodontic treatment and that the compliant and non-compliant groups carried on their self-caring activities similarly. Besides, no links were found between self-care of the patient and parental attitude; therefore, it seems impossible to associate the effect of familial conditions with self-care.
It is important that the orthodontist and pediatric dentist acknowledge that a non-compliant patient is not a difficult patient. Instead, they have a different personality and higher levels of anxiety that requires special attention. In order to gain successful treatment results, pediatric dentists and orthodontists need to assess the adolescent patient in relation to both psychological, personality and treatment aspects. Assessments may be carried out using well-established methods to gain more knowledge about the individual patient. Through proper knowledge of the pattern of anxiety, a child follows in sequential dental visits a flexible behavioral management protocol should be adopted as mentioned in previous research.  Various techniques can be used in order to overcome the raised state anxiety levels of the child's patients when they enter the orthodontic clinic. Psychodrama, role-playing or relaxation techniques practiced by a psychological consultant may be helpful. Besides these techniques, educating the child patient about the treatment protocol would help minimize state anxiety of the patient. Also, conscious hypnosis could be used as a method to minimize state anxiety and to advance cooperation during dental visits.  Possible limitations of this study include small sample size and family variables that could not be controlled (e.g., schooling) precluding drawing any general conclusions from the result. Further research in this field with larger sample groups is warranted.
| Conclusion|| |
Because of limitations of this study, it can be concluded that:
- Authoritative attitude of the father is found to be dominant at the level of state anxiety of the child. When the influence of the father on the child's behavior is considered, it would also be wise to ask the father to be present at the first few appointments of the orthodontic treatment.
- No differences existed between the compliant and non-compliant groups in terms of self-definition and self-evaluation.
- Non-compliant patients revealed a high state anxiety level. This showed that these children, who might have consequently affected compliance negatively, met the dental treatment duration with apprehension.
- No relation was found between the effect of familial conditions with self-care.
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[Table 1], [Table 2]