behavior rating scales
DESCRIPTION
Behavior Rating ScalesTRANSCRIPT
GOOD MORNING
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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