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BEHAVIOR RATING SCALES

Contents

Introduction

Behavior Rating Scales Definition Ideal Characteristics Classification

Behavior

Response of organism to various stimuli or inputs, whether internal or external, conscious or subconscious, & voluntary or involuntary

Objective Methods

1. Physiological measures : e.g. heart rate, galvanic skin responses

2. Psychometric scales

3. Rating of behaviour during dental visits

4. Projective techniques

Behaviour Rating Scales

Merell 1994 - A standardized format for the development of summative judgements about a child’s or adolescent’s behavioral characteristics, supplied by an informant who knows the child well

Ideal behavior rating scale

Reliable - high level of intra and inter examiner reproducibility

Valid

Simple, easy to use & easy to communicate

Quick & accurate without special instruments or special instructions

Able to distinguish between a handicapping & non handicapping trait

Objective in nature & yield quantitative data – analyzed by current statistical methods

Classification

Psychometric scales

Observational scales

Scales based on projection techniques

Psychometric scales

Based on questionnaires

Usually needs to be filled by parent especially if child is small – not able to comprehend

Older children can attempt to answer on their own

Eg – Children’s Fear Survey Schedule (CFSS) Modifications of CFSS Corah’s dental anxiety scale & modification

Children’s Fear Survey Schedule

Scherer & Nakamura - 1968Fear survey schedule for children (FSSC)9 – 12 years

80 items : Measure specific fears in categories of school, home, social, physical, animal, travel, classic phobia & miscellaneous

5 point Likert-scale - “None” to “Very much”

High reliability & validity in childrenCumbersome - limited use despite established

validity

Children’s Fear Survey Schedule Revised

Ollendick 19833 point scale – “None”, “Some”, “A lot”7 – 18 years

Dental subscale - Children’s Fear Survey Schedule

Cuthbert & Melamed

15 items related to various aspects of dental treatment

5-point scale ranging from 1 (not afraid) to 5 (very afraid)

Total score – 15 to 75> 38 – significant clinical dental fearDifferentiate between patients with high & low

dental fears

DentistsDoctors Injections (shots)Having somebody

examine your mouthHaving to open your

mouthHaving a stranger touch

youHaving somebody look at

you

The dentist drillingThe noise of dentist

drillingThe sight of dentist

drillingHaving somebody put

instruments in your mouthChokingHaving to go to a hospitalPeople in white uniformsHaving the nurse clean

your teeth

CFSS- DS Short Form

Shorter form of CFSS-DS 8 items Total score ranging from 8 to 40

Corah’s Dental Anxiety Scale

4 item measure

Respondents are asked about 4 dentally related situations & are asked to indicate which option is closest to their likely response to that situation

1. If you had to go to the dentist tomorrow for a check-up, how would you feel about it?

2. When you are waiting in the dentist's office for your turn in the chair, how do you feel?

3. When you are in the dentist's chair waiting while the dentist gets the drill ready to begin working on your teeth, how do you feel?

4. Imagine you are in the dentist's chair to have your teeth cleaned. While you are waiting and the dentist or hygienist is getting out the instruments which will be used to scrape your teeth around the gums, how do you feel?

Scoringa = 1, b = 2, c = 3, d = 4, e = 5Total possible =4 - 20

Anxiety rating:9 - 12 = moderate anxiety but have specific stressors that should be discussed & managed13 - 14 = high anxiety15 - 20 = severe anxiety (or phobia), requires the help of a mental health therapist for management

5th question relating to local anesthetics as it is a major cause of anxiety for many individuals (Humphris, Morrison, Lindsay)

Same options for all 5 questions, & rephrased to be in a more clear order of anxiety

Modified Dental Anxiety Survey

Inexpensive (useful in epidemiological settings)FlexibleEasy to administerContinuous score ranges : easily compiled &

processed statisticallyInternally consistentHigh test retest reliability & validity

Advantages

Cumbersome - limited use in very young children

Parents may not accurately predict fear in child

If filled by children – meaning given to each word may vary between children

Cannot be used in children with disabilities

Disadvantages

Observational Scales

Behavioral traits of child are observed by dentist & superimposed on ratings mentioned in the scales

Eg Frankl’s behavior rating scale and its modification Sarnat behavior scale Wright’s classification of cooperativeness of children Lampshire’s classification of behavior

Introduced by Frankl in 1962, most common4 categories of dental behavior

Frankl’s Behavior Rating Scale

Definitely negative

Refusal to treatment

Crying forcefully

Fearful or overt

evidence of extreme negativism

Negative

Reluctant to accept

treatment, uncooperative

Some evidence of negative

attitude but not pronounced

Sullen, withdrawn

Positive

Acceptance of treatment, at

times cautious

Willingness to comply with

dentist, at times with reservation

Follows dentist’s directions

cooperatively

Definitely positive

Good rapport

with dentist

Interested in dental

procedures

Laughing and

enjoying situation

– Helpful to indicate change in behavior– For eg :

• (--) (+) after TSD

Definitely negative• (- -)

Negative • (-)

Positive • (+)

Definitely positive • (++)

Wright’s Modification

• Smiles, offers information, initiates light conversation, gives positive responsesActive cooperation

• Indifferent, but obedient, follows instructions, quiet Passive cooperation

• Needs convincing, mild crying• Follows instructions under pressureNeutral, indifferent

• Seizes hand of dentist, not relaxed• Sits and stands alternatively

Opposed, disturbs work

• Cries, refuses to sit or enter the dental office

Completely uncooperative,

strongly opposed

Sarnat’s Scale

• 1975• 3 main categories

Co operative children

Children lacking co operative

ability

Potentially co operative children • Uncontrolled• Defiant• Timid• Tense co

operative • Whining

Wright’s Classification

Cooperative

Minimal apprehension

Reasonably relaxed

Good rapport with dentist and dental team

Show interest in dental procedures & often enjoy the situation

Dentist can work efficiently & effectively

Lacking Co Operative Ability

Lack ability to co operate because of mental or physical immaturity due to age or special

conditions

Includes • Children less than 2 ½ years of age ( pre

cooperative)• Children with specific debilitating

handicapping conditions, with mental and physical deficiencies

Potentially Cooperative

Include the “behavior problem” children

Have ability to co operate but do not

Behavior due to subjective/objective fears

Uncontrolled

Usually in 3-6 years

Throws a tantrum which might begin in reception area

Characterized by tears, loud cry, physical lashing out, flailing of hands

and legs – suggestive of acute anxiety or fear

If seen in older children indicates a more deep rooted problem which might also present as adjustment problems in

all settings

Hides behind parent but doesn’t offer physical resistance at attempt to

separate

May sob or whimper

Timid

Commonly in elementary school age

Child avoids eye contact, verbal responses usually in the form of

negative spech – “I won’t”, “I don’t want to” etc or totally non – existent

Usually branded stubborn or spoilt

Defiant

Tense Cooperative

Borderline behavior

Accept treatment but are extremely tense

Often revealed by body language

Patient’s eye follows movements of dentist and dental nurse

Tremor in voice

Perspiration on hands or eye brows

Whining

Allow dentist to perform the procedure but whine (often without tears) throughout treatment despite

encouragements

Frequently complain of pain

Whining may be a compensatory mechanism

• In 1970

• Physically & emotionally relaxed• Cooperative through out treatment

Co operative

• Children are tensed but will cooperateTense co operative

• Avoid treatment initially, hide behind mother, avoid looking or talking

• Eventually accept treatment

Outwardly apprehensive

Lampshire’s Classification

• Afraid of treatment• Require support to overcome it –

modeling, desensitization etcFearful

• Passively resists treatment using techniques successful in other situationsStubborn/defiant

• Agitated• Resorts to kicking & screaming

Hypermotive

• Physically, mentally or emotionally handicappedHandicapped

• Children less than 2 ½ to 3 yearsEmotionally immature

Since rated by dentist himself – easy to administer

Non intrusive when in use

Found to have high reliability (Frankl, Melamed, Wright, Aartman review 1996)

Advantages

Not much correlation between these methods and others – hence doubtful validity (ten Berge, Melamed, Winer)

Measures situational fear – chances of operator bias – behavior in one situation affects ratings in another

Inter examiner values may vary

Difficult to analyze behavior of children who have developed coping mechanisms, although fearful not expressed

Disadvantages

Projection Techniques

• Also called self – report methods

• Suggest a way of revealing unconscious or hidden emotions

• Based on a child’s interpretation of pictures, drawings etc.

• Developed out of Draw-a-Person Test• 9 x 11 sheet of paper, ask to draw a same gender

person – size of drawing will show amount of anxiety• Smaller, constricted – greater anxiety

• Letting a child draw a picture of a person & the interpretation of pictures in stories

• Children’s drawings & narratives can provide a unique window into their inner experiences, particularly when they have experienced stress & anxiety

Drawings

• Advantages – – Usually non directive– Require no simple right answers– Help identify feelings & desires that subjects may not

be consciously aware of or able to express verbally, besides being nonthreatening

– Transcends language limitations & cultural barriers– Takes little time to administer– Usually enjoyable activity

• Image of a thermometer

• Child selects a point on the thermometer to rate anxiety, where 0 = no anxiety, and 10 = extreme anxiety

Anxiety Thermometer

• A horizontal line marked 0 to 10 between ‘no pain’ & ‘worst pain possible’

• Risk of giving objective results as it is difficult to isolate a child’s pain experience from other emotional states

• Failure to distinguish between anxiety & pain may result in children receiving inappropriate treatment for their current state (different managements for pain & anxiety)

Visual Analogue Scale

• Visual analogue scale • Row of 6 faces ranging from very happy to very

unhappy• Point at which face they felt most like at the

moment

• Scoring – o 1 : most positive affect faceo 6 : most negative affect face o 5 & 6 : high dental fear

Facial Image Scale

Wong Baker Faces Pain Rating Scale

• 3 years and older

Oucher Pain Scale

• Beyer 1980• Color, laminated poster

instrument• 3- 12 years• 2 separate vertical scales: • Numeric scale (i.e., 0–100) for

older children• Photographic scale for younger

children• 3 ethnic versions validated:• Caucasian, African-American &

Hispanic

• Series of 8 paired drawings of a child• Each pair – a child in non fearful pose & a fearful

pose• Indicate for each pair which picture more

accurately reflects his feelings at the time

Venham’s Picture Scale

• Scores determined by summing the number of instances in which the child selects the high fear stimulus

• Buchanan 2005• 4 item computerised trait dental anxiety scale,

using faces as a response set• Reliable & valid for children from 6 years old

• Questions :– Having to have dental treatment the following

day– Sitting in the waiting room– About to have a tooth drilled– About to have a local anaesthetic

injection

The Smiley Faces Program

Enable information to be obtained about a child’s feelings & thoughts about dental care which may be hard to obtain through other methods

Quick & easy to administer

Measures situational fear

Advantages

Expert is required to carry out interview & score the tests

Younger children misinterpret drawings of facial expressions more often than older children

Some pictures are ambiguous in what they portray & do take time to comprehend

Of limited use in children who cannot identify themselves with the pictures shown

Disadvantages

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