INTRODUCTION

The social behavior of individuals includes positive aspects such as social competence, which refers to efficiency during interactions, offering the possibility of developing organized behaviors, which can be useful and are generally expressed during a person′s life, and are usually perceived by the people surrounding the individual. Another positive aspect is the development of social skills, which allow specific social behaviors during social interactions. There are also negative aspects such as behavioral problems, which can be expressed either externally in the form of arguments and aggressions, or internally in the form of anxiety, depression, and isolation.¹

Social competence and behavioral problems have been assessed by some studies, showing an inverse relationship, so that the existence of some problems does not directly imply that others are absent. On the contrary, these studies provide opportunities to analyze ways of relating social skills and behavioral problems, as some of the assessed individuals showing low values on the behavior problems scales may also have poor levels of social competence, as well as poor skills development.²

It has been reported that the behavior of children, specifically during dental consultation, can be aggressive, hysterical, fearful, or apprehensive.³ These behaviors have been linked to the stages of growth and development of each child, health characteristics, parents′ socio-cultural conditions, and other influential aspects that are not direct but have important implications. This include the relationships of children with parents, teachers, and other children in various contexts such as the church, the institutions where parents work, and the community.⁴⁾⁽⁵

This is why dental care should not use fixed parameters or pre-set management protocols, since each child is different and has specific behaviors and various behavior disorders, which must be identified prior to the first appointment, in order to be addressed in subsequent sessions. In the presence of fear or lack of cooperation by the child, treatment quality will be poorer than expected, so timely identification could help implement appropriate measures to adapt to this type of patients, achieving a favorable prognosis, with an ideal behavior by children requiring dental care.⁶⁾⁽⁷

In the year 2000, other authors⁸ studied some factors influencing dental care, the behavior of children or their parents, and previous dental care experiences, finding out that these influence the current state of anxiety and suggest the need to consider patients behavior, as well as environmental factors.⁹⁾⁽¹¹ This can provide dentists with a good approximation to potential behavioral problems during dental treatment.

It is therefore important to evaluate children′s behavior prior to dental consultation, since the effectiveness and adherence to dental treatments in these ages greatly depend on their behavior during appointments. It is also necessary to reinforce and teach social skills in order to improve their behavior and to avoid possible future distress in dentist-patient relationships, preventing the adequate maintenance of oral health. In addition to evaluating children′s aggressive behaviors and related factors, as well as their characteristics, it is also necessary to analyze parents′ behavior.

Taking these factors into account, the objective of this study was to describe the social skills, behaviors and behavioral problems of children during dental consultation at a teacher care center in the city of Cartagena (Colombia).

MATERIALS AND METHODS

This was a cross sectional observational study in children living in the city of Cartagena or neighboring municipalities, attending dental consultation at Universidad de Cartagena′s comprehensive clinics, in the Undergraduate Dentistry Program and the Graduate Pediatric Dentistry Program during the year 2013. Only those children whose parents filled in and signed written consent were selected, after explaining them the goals of the study, as well as the absence of risks and the contribution of this study to improving the quality of dental care in children of these ages, based on existing national regulations.¹² In addition, the following type of kids were excluded: children with medical conditions and systemic disorders such as cognitive impairment, learning difficulties, motor problems, or Down′s syndrome, as well as children classified as "difficult handling" based on Frankl test, taking into account negative values for their exclusion.¹³

In total, 250 children of both sexes were invited to participate; the children were 5 to 8 years of age, and 59.5% were males. In addition, 45% of them came from lower socio-economic groups (stratification 1 and 2 in Colombia, based on the DANE classification). The calculated sample size was 205 children, assuming a type I error of 5% and expected variability (SD = 0,20) for the average of the main aspect to be assessed in the study (total average of social skills). This size included a 10% increase in the total calculation (n = 186) to prevent failures in non-response rate or incomplete responses (questionnaire response rate was 100%).

The children′s parents were asked to fill a first questionnaire including socio-demographic and family factors in order to learn about social stratification, educational level, number of household members, marital status of main providers, occupation, working hours, and family type (nuclear, monoparental, binuclear, and extensive, according to type of members). On the other hand, the children were evaluated according to the behavior they presented during dental consultation through the Frankl scale.¹³ This scale measures the behavior of children at different stages of dental care, classified in the literature like this: 4: positive; 3: slightly positive; 2: slightly negative; 1: negative. This scale has been widely used in Latin America and in countries such as Colombia¹⁴ to analyze children′s behavior in dental consultation, and in this study was used to identify children of difficult management during the first appointment and to exclude them from the study. In addition, it was used as a scale in the variable of behavior.

At the same time, the parents were applied a second instrument called Preschool and Kindergarten Behavior Scales (PKBS),¹⁵ whose structure factor, in its second version in Spanish, was evaluated by Benitez et al¹⁶ in 2011, with a population of Spanish-speaking children. This scale assesses two dimensions: social skills, and behavioral problems in children aged 3 to 8 years. There are 10 items for the first dimension (social skills) and 13 items for the second dimension (behavioral problems). Children′s behavior was evaluated with the following categories of response: never = 1, sometimes = 2, frequently = 3.

To explore the two dimensions, parents chose the answers that best described the usual behaviors of their children. They should only choose one of the options indicated. The minimum score for the social skills dimension was 10 points, indicating that the child had adaptive problems. The maximum score was 30 points. Higher scores showed that the child had good social skills. For the behavioral problems dimension, the minimum score was 13 points and the maximum was 39 points.

Higher scores showed that the child had behavioral problems. To assess children′s behavior, the researchers used data obtained from children in dental consultation (Frankl scale) as well as from parents based on the Preschool and Kindergarten Behavior Scales (PKBS). In the event that parents were not able to attend consultation, a home visit was scheduled to apply the different questionnaires.

Cultural validation of the PKBS and the instrument of socio-demographic and family characteristics was conducted by the "criterion of judges", consisting in sending both instruments to three experts (two psychologists and a sociologist) for them to determine if the vocabulary and structure of each scale questionnaire were not inducing participants to misunderstand the actual questions. Once approved by the judges, both instruments were subjected to scrutiny through a pilot test with 10 volunteer subjects, providing that they had characteristics similar to those of the target population. These results allowed evaluating the behavior of the answers based on the literature findings in Latino populations with similar sociodemographic characteristics.

Trained personnel gave the surveys to participants during the second dental appointment, in order to provide them with all the required information to complete all the fields and to answer any possible questions. Similarly, the researchers conducted an audit of data, selecting at random 10% of the total number of questionnaires already completed, after the first day of assessment, in order to ensure that all the items had been completed and that they assessed the quality of the information provided by respondents.

On the other hand, all invited subjects were provided with the necessary information to be able to accept to participate in the study. Taking into account that one of the evaluations would be carried out in children, the parents or guardians′ consent was required in order to ensure the protection of the children at the time of making decisions. Similarly, detailed explanations on data collection were provided to the children, who were asked for their consent to participate.

Parents were explained the risks that children would be exposed to in participating in this study, as well as the future benefits of the results. This project was submitted to the Universidad de Cartagena Ethics Committee and to the Scientific Committee of the Program′s Research Department, obtaining the respective ethical approval according to Agreement 04 of 2012, and was classified as minimal risk (according to Colombia′s Ministry of Health Resolution 8430 of 1993).

For data analysis, normality of the distribution was verified through the Kolmogorov-Smirnov test, used for studies with large sample sizes (n > 100).¹⁷ Univariate analysis was conducted with averages and standard deviations. Comparison between the averages obtained from scales of skills and behavioral problems in different sex and age categories was conducted with t-test and one-way Anova test, respectively, assuming a probability value limit for significance (p < 0.05). In addition, to evaluate association among categorical variables, the Chi² test was used (p < 0.05). The statistical analysis was performed in the STATA™ software for Windows 10.1 (Stata Corp. LP, College Station, TX, USA).

RESULTS

(Table 1) describes the characteristics of the study population. The sample finally consisted of 205 individuals, 69.8% of whom came from clinics intended for the practicum of students of the Undergraduate Dental Program. 68.3% of the evaluated children live with both parents, and in 54.6% of cases the mother is the only income provider. Concerning type of family structure, the highest percentage (42%) were nuclear families (consisting of father, mother, and the child and his/ her siblings).

Table 1 Characteristics of the study subjects 

Note. * Numerical variables categorized for analytical purposes; * NA = data do not allow classification

Global analysis of the Frankl scale according to sex and clinic (Table 2) shows that the item of "positive behavior" presented the highest percentage in all cases; however, no statistically significant differences were found. Similarly, there was no significance in terms of the other sociodemographic and family characteristics of the study population on the above-mentioned scale (these data are not shown in tables because they are not relevant for the analysis).

Table 2 Analysis of the Frankl scale according to sex and type of clinic where child is treated 

Note. * NS= not significant for the probability chi² test (p < 0,05)

Analysis of the social skills scale according to age group (Table 3) showed statistical significance in terms of "helps a friend with difficulties" (p = 0.03), "shares with others" (p = 0.00) and "is friendly with adults" (p = 0.05), and greater averages were evident as age progressed. With regard to the comparison of averages for each item of the scale with sex, no statistical differences were found (Table 4). Concerning the clinic where the children were treated, the only significance was found in terms of "smiles and responds to others" (p = 0.05) (Table 5).

Table 3 Analysis of the social skills scale according to age group 

SD: Standard deviation; * Statistically significant differences with ANOVA test

Table 4 Analysis of the social skills scale taking sex into account 

SD= standard deviation

Table 5 Analysis of the social skills scale taking into account the clinic where child was treated 

Note. * Comparisons that showed values of probability with statistical significance in the Student´s t test.

Analysis of the scale of behavioral problems, taking into account the comparison of averages for each item of the scale with the kids ages (Table 6), showed that there were statistically significant differences with "shouts when is angry" (p = 0.02) and "disobeys rules" (p = 0.02). Concerning the comparison of averages for each item of the scale with sex, there was statistical significance with "responds to the affection of others" (p = 0.01), "is physically aggressive" (p = 0.01) and "is hard to be consoled" (p = 0.05) (Table 7). Finally, in comparing the averages for the scale of behavioral problems with type of clinic where kids were treated, there was significance with the following items: "is fearful or nervous" (p = 0.03), "intimidates other children" (p = 0.00), "seems sad or depressed" (p = 0.05), and "is too sensitive to criticism" (p = 0.01) (Table 8).

Table 6 Analysis of the behavior problems scale considering age in years 

SD: Standard deviation; * Statistically significant differences with the ANOVA test

Table 7 Analysis of the behavior problems scale taking sex into account 

SD: Standard deviation - * Statistically significant difference with the Student´s test.

Table 8 Analysis of the behavior problems scale taking into account the clinic where child was treated 

Note. * Comparisons that showed values of probability with statistical significance with the Student´s t test.

DISCUSSION

The present study demonstrated that children′s social skills are possibly related with factors such as good behavior during dental consultation, nuclear family (which was the most prevalent), an upbringing patterns. In addition, most participating children were over seven years of age. The following items: "is friendly with adults", "helps a friend in trouble", "shares with others", "smiles and responds to others" were statistically related to social skills, agreeing with the results of other studies,⁴ which highlight the importance of both father and mother performing the parenting role, by setting rules and limits that promote high levels of commitment with surrounding individuals, as well as an adequate development of social skills. It is therefore possible to assume that poor upbringing in terms of discipline and supervision fails to promote a healthy development of children.

The results of the present study point out that the behavior of children according to Frankl scale was positive for the majority of cases. Similar results were demonstrated by Abushal and Adenubi¹⁸ in 2009, and Ferro et al¹⁹ in 2010. This situation may be in part due to the fact that in the presence of their parents, children feel more secure and confident since they feel supported and protected. The findings of the present study suggest that there is a low frequency of children with behavioral problems (13.6% according to the Frankl scale and low scores according to the PKBS behavior scale), perhaps because some factors contributed to avoid them, including the nuclear type family and the company of parents.

Concerning family type, in 2010 Rodríguez⁴ argued that the nuclear family and promoting consistency in parenting patterns are aspects that help to decrease the likelihood of developing behavioral problems in children, achieving stability and security, and avoiding inadequate attitudes of isolation and inclusion in alternative groups. In addition, the company of parents has been reported in several studies, generating child respect for norms of behavior promoted by parents at home.⁶

The items showing values with statistical significance in terms of behavioral problems were: "yells when is angry", "disobeys rules", "is physically aggressive", "is fearful or nervous", "intimidates other children", "seems sad or depressed", and "is too sensitive to criticism". This may be due to parents′ stress associated with certain factors of lack of opportunities, such as low level of social stratification, and poverty. These parents may treat their children in rude and inappropriate manners when inculcating discipline patterns, thus producing aggressive behaviors. A study conducted by Cabrera et al²⁰ in 2012 shows that most children of low social stratification are corrected with rudeness, which is associated with parental stress, causing further negative behaviors.

Children′s behavior during dental consultation can be influenced by multiple factors, including age, sex, type of household, education of parents, social stratification, social skills, and behavioral problems. This is why dental professionals dealing with children must take on the challenge of controlling the interaction of these factors to ensure treatment success during consultation.^21)(22)(23 Although the literature reports other factors that may be important to create positive behavior by children during dental consultation, such factors were not evaluated in this study. However, in 2013 Lin et al²⁴ concluded that family plays an integral role-and the most important one-in both the psychology of child and the socio-cultural context. This is why the behavior of the pediatric patient can depend on two elements: modeling (experiences learned through models such as the mother and siblings), and conditioning (experiences during the consultation).

Concerning the educational level of parents and the number of members in the family with respect to the averages of the scales, the present study showed that these two factors were not determinant for children to express a positive or a negative behavior.

In terms of number of family members, this was not a factor with statistical significance in the present study, disagreeing with the findings by Mannaa et al²⁵ in 2013, where pediatric patients with large families and parents with low education levels showed negative behaviors during dental care. These results are similar to the findings by Kade et al,²¹ who concluded that children′s behavior during dental consultation was influenced by the parents′ educational level, showing an increase in inappropriate behavior by children as schooling decreases.

In relation to age as a variable, all study subjects had a good behavior since the session in which the instruments were applied (the second session), which could be influenced by the knowledge the health professional has about each child, because of specific behavior patterns, taking into account that they go through different stages of growth and development. In studies conducted by Soto and Reyes²⁶ in 2005 and Kade et al²¹, they showed that the age of 3 to 4 years is the best age for children to see the dentists because it is the period with greater number of manifestations of fear; therefore in younger ages there could be more failures in consultation. This suggests that adaptation of the child to the professional should most likely occur in early years, in order to start the conditioning and habits to the attention offered during dental consultation through good management of the patient with specific behavior techniques.

According to the findings by Muhammad et al²⁷ in 2011 and to other reports,^28)(29)(30 in most cases parents prefer non-pharmacological techniques, including positive reinforcement, effective communication, tell-show-do, distraction, modelling, and nonverbal communication techniques, and both parents and children tend to feel apprehensive about pharmacological techniques (sedation with nitrous oxide, conscious sedation, or general anesthesia), taking into account that, without any medication at all, and with proper implementation of the techniques, intervention by the professional can be achieved as well as a positive adaptation of children, without creating additional risks that can lead to other more aggressive techniques.

In considering sex as a variable in a study conducted by Arnrup et al,³¹ the researchers found out that girls showed a shy behavior, while boys were more extroverted. These results do not coincide with those reported in the present study, since sex as a variable showed no significant differences with regard to behavioral problems.

This study was conducted with the intention of obtaining information regarding children′s social development; this is why it was necessary to include parents as informants, since they can provide information about emotionality and emotional regulation; however, the information from teachers is also important in these cases, as they provide information about social behavior.

The main limitation of the present study was the use of a single informant, since only the parents were involved, as access to teachers was restricted. This created lack of triangulations of the information obtained from the perspective of each individual involved in the context of the child. However, due to the type of instruments that have been validated in the literature,^{13)(14)(15)(16} these findings constitute a significant approximation to the skills and social behaviors of children during dental consultation. Although it is clear that, with the observed results of association, it is not possible to ensure its causality due to the limitations of cross-sectional studies, which measure two variables at the same time.

CONCLUSIONS AND RECOMMENDATIONS

Based on the results, it can be concluded that the children who participated in this study showed a good behavior, good social skills, and there was a low-frequency of behavior problems. The scales used in the present study-not including symptoms that lead to an accurate diagnosis of social skills and behavior-only allowed detecting the need to implement strategies that will help maintain and strengthen the manifested positive attitudes and to avoid the development of behavior disorders. On the other hand, the results may be influenced by the company of parents during the sessions or by previous positive experiences of children, as well as by good nuclear family structures; detecting these associated factors promotes research into each of them, to establish the degree in which they influence the behavior of children and the existence of behavioral disorders.

It is therefore recommended to use these results before consultation so that the dentist knows the child′s characteristics in terms of social skills and behavior. Similarly, in the presence of severe cases, it is necessary to use measures of adapting to the consultation based on the factors with statistical significance in the present study. Finally, it is necessary to carry out a follow-up study, which, with a design including more validity in relation to causality, could provide definite results in this aspect to be used with greater certainty in situations occurring in dental consultation in the future.

ACKNOWLEDGEMENTS

To the Board of Directors of Universidad de Cartagena School of Dentistry for the academic and administrative support for the completion of this project. To the undergraduate dental students (Inés Castro and Alejandra Mercado) in the 2013 class, for the support in data collection for the present study.

CONFLICT OF INTEREST

The authors declare not conflict of interest