|Year : 2016 | Volume
| Issue : 2 | Page : 128-133
Self reported behavioral and emotional difficulties in relation to dentition status among school going children of Dilsukhnagar, Hyderabad, India
Adepu Srilatha, Dolar Doshi, Madupu Padma Reddy, Suhas Kulkarni, Bandari Srikanth Reddy
Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
|Date of Web Publication||14-Apr-2016|
Dr. Adepu Srilatha
Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Road No 5, Kamala Nagar, Dilsukhnagar, Hyderabad - 500 060, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Oral health has strong biological, psychological, and social projections, which influence the quality of life. Thus, developing a common vision and a comprehensive approach to address children's social, emotional, and behavioral health needs is an integral part of the child and adolescent's overall health. Aim: To assess and compare the behavior and emotional difficulties among 15-year-olds and to correlate it with their dentition status based on gender. Study Settings and Design: A cross-sectional questionnaire study among 15-year-old schoolgoing children in six private schools in Dilsukhnagar, Hyderabad, India. Materials and Methods: The behavior and emotional difficulties were assessed using self-reported Strengths and Difficulties Questionnaire (SDQ). The dentition status was recorded by the criteria given by the World Health Organization (WHO) in the Basic Oral Health Survey Assessment Form (1997). Statistical Analysis: Independent Student's t-test was used for comparison among the variables. Correlation between scales of SDQ and dentition status was done using Karl Pearson's correlation coefficient method. Results: Girls reported more emotional problems and good prosocial behavior and males had more conduct problems, hyperactivity, peer problems, and total difficulty problems. Total decayed-missing-filled teeth (DMFT) and decayed component were significantly and positively correlated with total difficulty, emotional symptom, and conduct problems scale while missing component was correlated with the hyperactivity scale and filled component with prosocial behavior. Conclusion: DMFT and its components showed an association with all scales of SDQ except for peer problem scale. Thus, the oral health of children was significantly influenced by behavioral and emotional difficulties; so, changes in the mental health status will affect the oral health of children.
Keywords: Adolescents, behavior, dentition status, emotion, mental well-being
|How to cite this article:|
Srilatha A, Doshi D, Reddy MP, Kulkarni S, Reddy BS. Self reported behavioral and emotional difficulties in relation to dentition status among school going children of Dilsukhnagar, Hyderabad, India. J Indian Soc Pedod Prev Dent 2016;34:128-33
|How to cite this URL:|
Srilatha A, Doshi D, Reddy MP, Kulkarni S, Reddy BS. Self reported behavioral and emotional difficulties in relation to dentition status among school going children of Dilsukhnagar, Hyderabad, India. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2019 Dec 9];34:128-33. Available from: http://www.jisppd.com/text.asp?2016/34/2/128/180419
| Introduction|| |
The World Health Organization (WHO)  has defined "health" as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Further, the role of mental well-being and social well-being as key determinants of health has been emphasized by the WHO.
Mental well-being is a state in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.  Social well-being means the ability of a person to adjust with others in his social life, at home, at the workplace, and with people. Essentially, social well-being includes the harmonious interrelation and interaction of human beings.  Behavior is the manner of acting or of conducting oneself, which also depends on one's own feelings and emotion.  An emotion is a complex state of feeling that results in physical and psychological changes that influence thought and behavior.
Emotional and behavioral problems are among the most prevalent chronic health conditions of childhood and often have serious negative consequences for a child's academic achievement and social development.  For children to meet the developmental milestones, learn, grow, and lead productive lives, it is critical that they be healthy. Also, for proper behavioral development, the child must be assured of emotional stability and moral stability, and should be provided with models of balanced conduct. 
It has been documented that children experience a significant range of mental, social, emotional, and behavioral health conditions and most of their problems are amenable to intervention.  Epidemiological studies have shown that around 18-22% of adolescents have signs of significant problems in adjustment.  Cohen et al. have provided strong evidence that negative mood states increase people's susceptibility to illness. 
Likewise, oral health is also linked to happiness and good general health and the literature supports that aesthetically acceptable and functionally adequate dentitions affect self-esteem, confidence, and socialization.  Also, oral health has strong biological, psychological, and social projections, which influence the quality of life. Thus, developing a common vision and a comprehensive approach to address children's social, emotional, and behavioral health needs is an integral part of the child and adolescent's overall health.
Though several studies have assessed the behavior and emotional difficulties among children and adolescents, ,, very few studies have reported their relation with oral health. Pattusi et al.  observed that behavioral problems, dental pain, and poor chewing function were associated with poor oral health and further, Renner et al.  investigated that mental health problems were associated with bruxism (night grinding only). Odoi et al. conducted a case-control study among 7-15-year-old schoolchildren and concluded that behavioral problems play an important role in the occurrence of traumatic dental injury.
Recognizing this importance, the present study aims to assess and compare the behavioral and emotional difficulties using the Strengths and Difficulties Questionnaire (SDQ) among 15-year-old schoolgoing children of private schools in Dilsukhnagar, Hyderabad, India and to correlate it with their dentition status based on gender.
| Materials and Methods|| |
A cross-sectional questionnaire study was conducted to assess and compare the behavior and emotional difficulties and to correlate it with their dentition status based on gender among 15-year-old-schoolgoing children of private schools in Dilsukhnagar, Hyderabad, India.
The study was approved by the ethical committee of the institutional review board. Anonymity and confidentiality of the respondents were maintained and participation was voluntary.
A pilot study was conducted on a convenience sample of 67 students of 15-year-old schoolgoing children for estimating the sample size, planning of the main study, and finalizing the survey pro foma. With confidence level of 95% and sampling error of 5%, the estimated sample size was a minimum of 396 subjects.
The information on the total number of secondary schools in Dilsukhnagar area, Hyderabad, India was obtained from the office of the concerned District Education Officer. Out of 32 schools, six schools were selected on a convenience basis. All children aged 15 years and who were present on the day of examination were considered for the study. The questionnaire was distributed in the classroom and children were given 15 min to complete it without discussion. Any query in understanding the questions was clarified by the principal investigator.
The behavioral and emotional difficulties were assessed using a 25-item self-reported SDQ.  SDQ was developed by Godmann et al. It measures both positive (strengths) and negative (difficulties) behavioral and emotional attributes on a 3-point Likert type scale (0 = Not true, 1 = Somewhat true, 2 = Certainly true). The 25 SDQ items are divided into five scales comprising five items each, i.e., emotional symptoms scale, conduct problems scale, hyperactivity scale, peer problems scale, and prosocial behavior scale.
Emotional symptoms scale, conduct problems scale, hyperactivity scale, and peer problems scale measure the behavioral and emotional difficulties and the prosocial behavior scale measures the social strength of a child.
After reversing the negatively worded prosocial behavior scale, each scale is calculated by adding the scores of the relevant items, thereby generating a score ranging 0-10 for each scale. To obtain the total difficulty score, all four difficulty scales (emotional symptoms, conduct problems, hyperactivity, and peer problems) are added together, and consequently generate a score ranging from 0-40.
Based on total difficulty score and individual scale scores, participants were categorized as Normal, Borderline and Abnormal [Table 1].
Dentition status was recorded by the criteria given by the WHO in the Basic Oral Health Survey Assessment Form (1997).  Decayed-missing-filled teeth (DMFT) score was calculated from the dentition status codes.
Statistical analysis was done using Statistical Package for Social Sciences Software (SPSS) version 12.0). Independent Student's t-test was used for comparison among the variables. Correlation between the scales of SDQ and dentition status was done using Karl Pearson's correlation coefficient method. The level of significance (P value) was set at 0.05.
| Results|| |
Out of 563 questionnaires distributed, 504 questionnaires were completed and included in the study (response rate: 89.4%). The study was conducted among 15-year-old schoolgoing children comprising 244 (48.4%) males and 260 (51.6%) females.
A statistically significant association was observed for the mean scores of strength and difficulty and its scales when compared according to gender. The mean score for total difficulty among males was 14.8 ± 4.6, which was significantly higher as compared to females (13 ± 4.8) (P = 0.000). When individual scales of total difficulty were considered, females reported significantly high mean scores for emotional symptoms (P = 0.006; 3.6 ± 2.2). On the other hand, males had significantly higher mean scores for conduct problems (3.7 ± 1.81), hyperactivity (4.3 ± 1.66), and peer problems (3.7 ± 2.04) scales (P = 0.0001). On the contrary, females had significant and more prosocial behavior (P = 0.00001; 8.1 ± 1.7) as compared to males (7.4 ± 1.8) [Table 2].
|Table 2: Comparison of mean scores of total strength and difficulty and its scales according to gender by Student's t-test |
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When dentition status was taken into account, the mean DMFT of the participants 1.3 ± 1.68 for males and 0.9 ± 1.47 for females, and this difference was statistically significant (P = 0.00). Though, the mean scores of both the decayed and filled components were lower among females (0.7 ± 1.27; 0.1 ± 0.5); significant difference was obtained only for the filled component (P = 0.007) [Table 3].
|Table 3: Comparison of mean scores of DMFT and its components according to gender by Student's t-test |
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Correlation of total difficulty and its scales with the dentition status revealed that the DMFT and decayed component were significantly and positively correlated with total difficulty (P = 0.02; P = 0.01), emotional symptom scale (P = 0.01; P = 0.04) and conduct problems scale (P = 0.02; P = 0.01). Nonetheless, the missing component was significantly and negatively correlated with hyperactivity scale (P = 0.006). When the strength, i.e., prosocial behavior was correlated, a significant and negative correlation was observed with the filled component (P = 0.001) [Table 4].
|Table 4: Correlation between total strength and difficulty and its scales with DMFT and its components by Karl Pearson's correlation coefficient method |
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Genderwise correlation of total strength and difficulty and its scales with the DMFT and its components showed that the decayed component was significantly and positively correlated with total difficulty scale (r = 0.1184) among males and with emotional symptom scale (r = 0.1026) among females. On the other hand, the missing component was significantly and negatively correlated with the hyperactivity (r = −0.1659) among females. The strength, i.e., prosocial behavior revealed a significant and negative correlation with the filled component (r = −0.1646) among males as compared to females (r = −0.09) [Table 5].
|Table 5: Correlation between total strengths and difficulties and their scales with DMFT and its components according to gender by Karl Pearson's correlation coefficient method |
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Based on the level of total difficulty, 59.3% of the participants were categorized as normal, 27.2% as borderline, and 13.5% in the abnormal category. When individual components of total difficulty were considered, a high percentage of females (6.5%) were in the abnormal category for emotional symptom scale when compared to males (2.5%). On the contrary, high percentages of males were in abnormal category for conduct problems scale (16.2%), hyperactivity scale (5%), and peer problem behavior scale (9.3%) in comparison to females (8.5%, 2.8%, and 6.2%, respectively) [Table 6].
|Table 6: Categorization of study participants based on their levels of total strength and difficulty and their scales and comparison according to gender |
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Likewise, when participants were categorized based on their prosocial behavior (i.e., strength), it was noted that 89.7%, 6%, and 4.3% were in the normal, borderline, and abnormal categories, respectively. It was observed that a high percentage of females were in the normal category (46.8%) in comparison to males (42.8%) [Table 6].
| Discussion|| |
The WHO Commission on Social Determinants of Health has recommended that governments should provide quality education that pay attention to children's physical, social/emotional, and cognitive development, starting in preprimary school.  Lewinsohn et al. reported that there is an increasing evidence of continuity of common mental disorders beginning in childhood to adolescents and early adulthood. Hence, for early detection and prevention, screening of behavioral and emotional difficulties in children and adolescents becomes essential.
In a review about oral health and mental illness by Ponizovsky et al.,  people with mental illness were more likely to have permanent tooth loss than other people from similar socioeconomic backgrounds. Similarly, Kisley et al. reported that the odds of having tooth loss were 3.4 times more in people with mental illness. Thus, understanding the health needs of people with psychological disturbances such as mental illness or behavioral problems becomes a consequential part for health care professionals including dentists.
In this study, the 25-item self-reported SDQ was used to assess the behavioral and emotional difficulties. On comparison with other questionnaires such as the child's behavior checklist,  SDQ has good validity and interinformant reliability as reported in previous studies. ,,, Further, SDQ is age-specific, significantly shorter, and can be used by workers who are not highly trained in the field of mental health. 
In the present study, the mean SDQ scores showed significant gender differences with girls having more emotional symptoms (P = 0.006) and prosocial behavior (P = 0.00001) and boys with more conduct problems, hyperactivity, and peer problem behavior (P = 0.0001). These findings were in accordance with other studies conducted by Svedin and Priebe  and Lundh et al. among Swedish adolescents, Roy et al. among Norwegian adolescents, and Issac et al. among schoolchildren of Indian origin in the United Arab Emirates (UAE). In contrast, in a study conducted by Black et al. among New Zealand secondary school students, SDQ scores were not statistically significant with gender (P = 0.97).
In our study, the overall dentition status was better among females with lower mean scores for total DMFT and the decayed and the filled components. The total DMFT and the decayed component were positively correlated with total difficulty, emotional symptom scale, and conduct problems scale. Nonetheless, the missing component was negatively correlated with hyperactivity scale. Genderwise correlation showed that the decayed component was positively correlated with total difficulty scale among males and with emotional symptom scale among females. The strength, i.e., prosocial behavior revealed a negative correlation with the filled component among males. A comparison of the above results with other populations could not be done due to the dearth of literature.
When the total difficulty and strength were considered based on their SDQ scores, around 59.3% and 89.7% of the study subjects were in the normal category. When individual components of total difficulty were considered, more girls were classified as having an "abnormal" score on emotional problems scale (6.5%) and boys on conduct problems (16.2%), hyperactivity problems (5%), and peer problems scales (9.3%). Similar findings were also seen in study conducted by Isaac et al. among Indian students in the UAE  wherein 4.7% of girls with emotional symptoms and 5.5%, 4.5%, and 1.9% of boys with conduct problem, hyperactivity problem, and prosocial behavior, respectively, had high abnormal scores. Likewise, in the present study when prosocial behavior was considered a high percentage of males were in the abnormal category as compared to females.
However, we acknowledge that our study had a few limitations. First, the data were based on the self-report and no behavioral observations or clinical indices were used to confirm this self-report measure. Second, the reversely scored items of SDQ would have been confusing and difficult to report by children. Therefore, the use of parent-and-teacher SDQ version, along with self-report, to examine the mental health problems would have been helpful. However, it could not be included in the present study due to logistic reasons. Further, within the confines of the present study only the school-based population was included and hence, the results cannot be generalized.
| Conclusion|| |
In the present study, the prevalence of emotional symptoms and prosocial behavior were more among girls and conduct problem, hyperactivity, and peer problem behavior were high among boys. It was observed that the DMFT and its components showed an association with all scales of SDQ except for peer problem scale. Thus, the behavior and emotional determinants of health also influence oral health. Therefore, the child must be secure of emotional and moral stabilities and balanced conduct for the maintenance of health.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]