|Year : 2012 | Volume
| Issue : 3 | Page : 195-200
Parental acceptance of pediatric behavior management techniques: A comparative study
I Elango1, DK Baweja2, PK Shivaprakash3
1 Department of Pediatric and Preventive Dentistry, The Oxford Dental College and Hospital, Bangalore, Karnataka, India
2 Department of Pediatric and Preventive Dentistry, B.R.S. Dental College and Hospital, Panchkula, Haryana, India
3 Department of Pediatric and Preventive Dentistry, PMNM Dental College and Hospital, Bagalkot, Karnataka, India
|Date of Web Publication||21-Dec-2012|
5/26 Thiruvalluvar Nagar, 1st Cross Street, Krishnagiri, Tamilnadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: To evaluate and compare the attitude toward behavior techniques among parents of healthy and special children in Indian subpopulation. Materials and Methods: Parents of healthy (Group A) and special children (Group B) watched videotape vignette of 10 behavior management techniques (BMTs) in groups and rated them using Visual Analog Scale (VAS). Group B parents were subgrouped as: Group B 1 (34 parents of medically compromised children), Group B 2 (34 parents of physically compromised children), and Group B 3 (34 parents of children with neuropathological disorders). Results: Both Group A and Group B subjects judged all techniques as "acceptable." Group B parents were less accepting to techniques than Group A parents, except live modeling. Contingent escape and live modeling were the first ranked techniques in Group A and Group B parents, respectively. Voice control (VC) and hand-over-mouth exercise (HOM) were the least accepted techniques in both groups. Parents with low income and less education were more receptive to the techniques studied. A total of 25.49% of parents in each group did not consent to the use of HOM. Conclusion: Factors such as having a disabled child, low income, and less education influenced parental acceptability. HOM should be used with great caution and clinicians should approach the issue of informed consent on an individual basis.
Keywords: Behavior management, child behavior, informed consent, parental acceptability, parental attitudes
|How to cite this article:|
Elango I, Baweja D K, Shivaprakash P K. Parental acceptance of pediatric behavior management techniques: A comparative study. J Indian Soc Pedod Prev Dent 2012;30:195-200
|How to cite this URL:|
Elango I, Baweja D K, Shivaprakash P K. Parental acceptance of pediatric behavior management techniques: A comparative study. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2019 Nov 15];30:195-200. Available from: http://www.jisppd.com/text.asp?2012/30/3/195/105010
| Introduction|| |
Behavior management is a comprehensive continuous methodology targeted to build relationship between child, parent, and doctor, aimed at eliminating fear and anxiety and ultimately building trust. It enables the dentist to forestall a positive dental attitude, to guide the child through their dental experience, and to perform quality treatment safely. Another integral aspect of child dental care is to provide parents with previous information of behavior management techniques (BMTs).  This delivery of information provides a mechanism by which parents can participate in treatment decisions with full understanding of factors related to their child's proposed dental care and helps in reducing situational parental anxiety.  Thus, insights into factors that influence parental perceptions are necessary.
The dental literature has various studies reporting parental acceptability of BMTs, ,,,,,,, but no study has reported the attitude of Indian parents. Moreover, there is a paucity of scientific data regarding special child parent's attitude toward various techniques employed in pediatric dentistry. Greater knowledge in this area could lead to better dentist-parent communication, better parent education, and ultimately better care of a special child. Thus, this study was undertaken to evaluate and compare the attitude and acceptance toward BMTs among parents of healthy and special children. The aims and objectives of the study were: 1) to assess mean rating and ranking for each BMT, 2) to assess the acceptance of each technique by parents of healthy children, 3) to assess the acceptance of each technique by parents of special children, and 4) to compare the level of acceptability between the parents of healthy and special children.
| Materials and Methods|| |
Subjects were randomly selected from the group of parents who reported to Department of Pedodontics and Preventive Dentistry, PMNM Dental College and Hospital, Bagalkot; Department of Pediatrics, Shri Hanagal Kumareshwar Medical College, Bagalkot; and Usha's Centre for Exceptional Children, Hubli. Study subjects were selected using the following criteria: Parenthood (parents of children aged 3-15 years with no previous exposure to BMTs), willingness to participate, and ability to view and understand the videotape. Parents of all socioeconomic status irrespective of their age, gender, income, educational status, and occupation were included. Selection continued until 102 parents of healthy children (Group A) and 102 parents of special children (Group B) were obtained. Group B parents were grouped as: Group B 1 (34 parents of medically compromised children), Group B 2 (34 parents of physically compromised children), and Group B 3 (34 parents of children with neuropathological disorders).
A master video tape depicting 10 techniques with prior explanation [Table 1] was made using a VHS recorder (Panasonic MD-900) and a lavalier microphone incorporated into the master VHS tape. The techniques were presented in identical sequence to all parents as follows: Tell-show-do (TSD), positive reinforcement (PR), live modeling (LM), contingent escape (CE), mouth prop (MP), voice control (VC), physical restraint by the dentist (PRD), hand-over-mouth exercise (HOM), oral sedation (OS), and general anesthesia (GA).
The videotape was 10 min long, with the duration of each technique ranging from 35 to 60 sec. Consent for videotaping and the use of the videotape for the study purpose was obtained from parents of each child shown in the videotape. Children appearing in the videotape were instructed to model as instructed/demonstrated while recording the technique and the age of the children appearing in the videotape ranged between 4 and 9 years.
Taping sessions were repeated until acceptable examples of all techniques were recorded. The videotape contained introductory comments (given by a different investigator) describing each technique in an identical dental clinical setup (except for GA). A single investigator performed all the techniques in the vignette (except for GA). Four faculty members from the Department of Pedodontics and Preventive dentistry, PMNM Dental College and Hospital, reviewed the tapes for validity and accuracy of presentation. Two techniques were retaped at the recommendation of this group.
The final content of the videotape included 10 techniques, in which the name of each technique was displayed for 5 sec followed by three visual still pictures. This was accompanied by brief explanation and actual demonstration of the technique with its goals. The descriptions and the goals presented in the videotape were consistent with the objectives and guidelines outlined by American Academy of Pediatric Dentistry. 
Demographic variables (name, age, gender, permanent address, educational status, income, and number of children) and informed consent were obtained by using parent information form. Parents were requested to rate the techniques using Visual Analog Scale (VAS; proposed by Clark and Spear, 1964). VAS has wide use in behavioral and neurophysiological disciplines. Several studies had used VAS ,,,,, and found it reliable in measuring parental acceptance. This scale also enables some form of non-parametric data to be expressed in parametric form. 
VAS is a 100-mm horizontal line with words "completely acceptable" and "completely unacceptable" at the left and right ends of the line. The words "completely acceptable" and "completely unacceptable" were illustrated by using images - green-colored (happy) face and red-colored (glum) face - at the left and right ends of the VAS to facilitate easy understanding of the scale. Anchor points depicted by coffee cups with different volumes of the liquid at respective places were incorporated at regular intervals of 25 mm for accurate marking of the perceptions [Figure 1].
Videotaped vignettes were projected using a laptop/LCD projector in the parent counseling room, and parents rated them in groups (3-5). The subjects were asked to mark their opinion by using a vertical mark that crossed the horizontal reference line. Following each technique, 10 sec were allotted for the subjects to rate the technique using VAS (i.e., How acceptable is this technique?), as well as to express their consent to the use of technique with "their" child if deemed essential during the dental procedure.
Demographic information was tabulated and the number of millimeters from the left anchor point to the vertical mark placed by the parent was measured. The most acceptable rating possible was 1 and the least acceptable rating possible was 99. The ratings on the scale were considered acceptable/unacceptable depending on their position relative to 50. A score below 50 was considered acceptable; lower the score, the more acceptable the technique, and the converse was true.  Mean VAS score was calculated for each technique in both groups.
Variables such as age (20-30 years; 31-40 years; 41+ years) gender, number of children (one, two, and three+), educational level (no education - below high school; high school education; degree level education), and social status were examined for their influence on parental rating. Only income was used to determine the social status of the parent.
Six social class categories described by Agarwal,  which linked Prasad's classification to All India Whole Sale Price Index (AIWPI) Series developed in relation to the base year 1993-1994, were combined into "high" group (which included high and upper high levels), "medium" group (which included upper middle), and "low group" (which comprised lower middle and poor) to increase the power of statistical analysis. Data were analyzed using "t" test, one-way analysis of variance (ANOVA), and Tukey's Honest Significant Difference multiple comparison test procedure.
| Results|| |
Distribution of demographic variables for each of the study groups is depicted in [Table 2]. Both Group A and B subjects judged all techniques as "acceptable." Group B parents were less accepting to all techniques when compared to Group A parents, except for LM [Graph 1]. Mean VAS scores were used to rank the techniques. The technique with the least mean VAS score was ranked first and so on. The first ranked technique by Group A subjects was CE, followed by TSD [Table 3], whereas LM and PR were the most preferred techniques by Group B subjects [Table 4].
|Table 2: Distribution of socio-demographic variables for each study group|
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Pair-wise comparison of Group B scores demonstrated that all techniques had significant differences between Group B 1 and Group B 3 subjects, while only PRD, OS, and GA yielded significant difference among Group B 1 and Group B 2 parents. Except for OS and GA, all techniques showed significant differences between Group B 2 and Group B 3 parents. HOM was considered unacceptable by Group B 3 [Table 5].
|Table 5: Pair-wise comparison by parents of Group B1, Group B2, and Group B3 by Tukey's Honest Significant difference multiple comparison test procedure|
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In contrast to Group A parents, Group B parents exhibited significant age differences for techniques like MP, OS, and GA. In group A, females were less accepting for BMT studied and this was converse in Group B parents. "Low"-income group parents were significantly more accepting for MP, aggressive and pharmacologic techniques. Parents with high level of education were less accepting to techniques studied in both the groups. Parents' perceptions toward BMTs were not influenced by the number of children possessed by the participating subjects.
A total of 25.49% of parents in each group did not consent to the use of HOM. GA was not approved by 19.61% and 16.67% parents in Group A and Group B, respectively. In Group B, 3.92% parents did not consent for the use of TSD and 1.96% parents did not consent for the use PR [Table 6].
|Table 6: Distribution of subjects with "no consent" for each technique studied|
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| Discussion|| |
All techniques were considered "acceptable" by both groups and this was similar to that reported by Lawrence et al.  and Abushal and Adenubi.  Different hierarchies of BMT acceptability were reported for each study group. The most accepted technique among Group A and Group B were CE and LM, respectively. Based on American Academy of Pediatric Dentistry (AAPD) call, to identify noninvasive procedures to help dentists deal with disruptive and uncooperative children, techniques like CE and LM were included for the present study.  As these techniques were not considered in previous studies, direct comparison of acceptability hierarchy to other studies was not possible.
With exclusion of CE and LM, the most accepted techniques in both groups were TSD and PR. These results were consistent with the results of many studies such as Murphy et al.,  Lawrence et al.,  Wilson et al.,  Scott-Garcia Godoy,  Abushal and Adenubi,  and Havelka et al. 
The least accepted techniques in both groups were VC and HOM These findings contradicted some earlier findings, ,,,, but were consistent with a study conducted on Saudi parents,  which claimed that the aggressive tone included in this technique might have affected parent's acceptance negatively. This was later revealed in a study by Eaton et al. 
OS was accepted more often than GA in a study by Murphy et al.  The findings from both groups in the present study paralleled this observation. Scott-Garcia Godoy  found that parents would have their child subjected to GA than HOM, and such reports were supported by the present study. This may be possibly due to less morbid nature of OS.
Parents of children with neuropathological disorder were more resistant to the acceptance of techniques than parents of medically and physically compromised children. HOM was considered unacceptable by parents of children with neuropathological disorder. Thus, having a disabled child might influence the acceptability rating of BMTs. Our findings were converse to those reported by Brandes et al.  who demonstrated that parents of disabled children were more accepting of BMTs than parents of healthy children, but this finding was not statistically significant; moreover, this study did not attempt to specify the type of disabling condition. This difference might have affected the parent's acceptance of technique negatively in the present study.
Rating of techniques in relation to age and gender yielded variable results. As was reported in a previous study,  the number of children did not influence the parental attitudes. However, parents belonging to low socioeconomic group were more accepting to certain behavioral techniques. This was in agreement with a study by Lawrence et al., which expressed that parents of low socioeconomic status may be more accepting to professional opinion and less likely to express dissatisfaction with a procedure. 
As was shown earlier by Abushal and Adenubi,  the present study also failed to receive greater approval toward some techniques from parents with high educational qualification. This is in agreement with Kramer's finding  which showed that parents with low educational levels are more receptive to professional advice.
All the mean scores were associated with high standard deviation, which indicated that a great variability in parental attitude existed. All techniques received parental acceptance except HOM which was rated unacceptable by parents of children with neuropathological disorder. Nearly one-third parents in each group did not consent to the use of HOM, which along with GA was less likely to receive informed consent in comparison to all the techniques studied. A small percentage of Group B parents expressed "No" consent for TSD and PR. These observations suggest that implementation of each technique should be considered an individual situation for informed consent in every case.
These differences in methodology could have influenced the outcome of this attitudinal study. The extent of these differences, as well as factors concomitant to this study methodology requires resolution in further studies.
- Different ethnicity of the participating parents
- Method of rating the videotapes
- Failure to analyze parents' stress level during technique rating
- No attempt was made to specify the severity of the disabling condition
| Conclusion|| |
Techniques like CE and LM were well accepted than TSD and PR. Hence, implementation and dissemination of these techniques are essential. Parents of special children were less accepting to techniques than the parents of healthy children, but significant differences were obtained only for some BMTs. Thus, having a disabled child might be a factor influencing the parental rating. Parental age, gender, and number of children did not exhibit exalting influence, whereas parents from "low"-income group and parents with less/no educational qualification were more receptive to some of the BMTs investigated. Cautious use of HOM and the routine of obtaining informed consent with prior technique explanation need to be stressed in our day-to-day practice.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]