Child dental fear as measured with the Dental Subscale of the Children's Fear Survey Schedule: the impact of referral status and type of informant (child versus parent).

OBJECTIVES: The first aim of this methodological study was to investigate the agreement between self-ratings of Children's Fear Survey Schedule (CFSS-DS). The second aim was to explore using differentiated cut-off scores, and to compare these cut-off scores with those commonly used. METHODS: Three different data collections included study groups (n = 497) of children and adolescents who had been referred to specialized pediatric dentistry clinics, and reference groups (n = 499) of dental patients and children rating the analyses were limited to the Östergötland sample (n = 210 + 228). Patients and their accompanying parents (mainly mothers) were asked to fill in the CFSS-DS independently. Cut-off scores on the CFSS-DS scale were determined using receiver-operating characteristic analysis; patient-parent agreement was illustrated with Bland-Altman plots. RESULTS: The patient-parent agreement was modest, particularly among those who were referred because of dental behaviour management problems (DBMP). Cut-off scores differentiated by age and gender, suggested by exploration according to two different methods, were with few exceptions clearly below the standard cut-off score. CONCLUSION: [corrected] The validity of parental ratings of their children dental fear should be questioned, particularly in high-fear populations. Self-ratings should, as far as possible, be used to complement parental ratings. One consequence of using the standard cut-off score is the risk of overlooking some patients needs for special attention. Further research is needed to establish and validate age-and gender-differentiated cut-off scores on the CFSS-DS.

Heritability of dental fear.

The objective was to test a hypothesized genetic component (i.e., monozygotic being more similar compared with dizygotic twins) in dental fear/anxiety by comparing the probandwise concordance. We analyzed data based on a dichotomous measure of Dental Fear/Anxiety and a continuous measure of Dental Fear Intensity from over 2000 twins, collected when participants were 13-14 years old and once again three years later. The hypothesis was confirmed, but heritability of Dental Fear/Anxiety was estimated to be higher for girls (0.77 at time 1 and 0.55 at time 2) than for boys (0.14 and 0.0 at times 1 and 2, respectively). Heritability of Dental Fear Intensity, however, was similar for girls (0.30 and 0.40 at times 1 and 2, respectively) and boys (0.47, 0.44). Studies of the etiology of dental fear/anxiety should take genetic vulnerability into account and include molecular biology measures. Possible heritability differences between girls and boys need attention.

A short-term follow-up of treatment outcome in groups of uncooperative child dental patients.

AIM: To evaluate the short-term follow-up outcome in four subgroups of uncooperative child dental patients referred to a specialist paediatric dental clinic in Sweden. METHODS: Seventy children, classified into four groups (based on fear, temperament, behaviour and verbal intelligence), were followed-up at their public dental clinics after termination of specialist dental treatment. Questionnaire assessments of children's dental and general fear, parental dental fear, emotional stress, locus of control and parenting efficacy were made by parents pre and post treatment and at follow-up and were analysed within and between groups. At follow-up, parents rated their children's coping and procedure stress, while treatment acceptance was rated by the dentists. RESULTS: Decreases in child dental fear were maintained at follow-up, although a third of children still had moderate or high dental fear. For those children who had been classified into the externalising, impulsive group, an increased risk of non-acceptance (RR=3.7) was indicated. The risk of dental fear at follow-up was increased for the group of fearful, inhibited children (RR=3.8). For the study group as a whole a poorer follow-up outcome could be predicted by avoidance behaviour (OR 12.9-16.6) and moderate or high post treatment dental fear (OR 6.5- 21.3). CONCLUSIONS: Fearful, inhibited child dental patients may need, due to dental fear, extra attention even after successful dental treatment at a specialist clinic. Externalising, impulsive children constitute a special challenge for dentistry. The continued need for adjusted management after termination of specialist treatment can be predicted from avoidance behaviour and post treatment dental fear scores.

Emotional and behavioural problems in Swedish 7- to 9-year olds with asthma.

BACKGROUND: The purpose of this study is to compare emotional and behavioural problems between preadolescent children with asthma and healthy children, and to explore if disease factors relate to problem scores. DESIGN: This was a cross-sectional study of 59 children, 34 boys and 25 girls, aged 7-9 years with mild (n = 11), moderate (n = 38) or severe (n = 10) asthma. A normative sample of 306 children in the same age range, 150 boys and 156 girls, was used as a comparison group. METHODS: Parents assessed emotional and behavioural problems using the Child Behaviour Checklist. Peak expiratory flow rate and urinary eosinophil protein X were used as measures of lung function and inflammation. Children were interviewed about activity restriction and symptoms during the last week using the Paediatric Asthma Quality of Life Questionnaire. Parents scored day, night and exercise-induced symptoms during the same week. RESULTS: On average, children with asthma were attributed more problems than healthy children of the same age and comparable family socio-economic status. Effect sizes were 0.80 (95% confidence interval 0.52-1.09) for total problems, 0.89 (0.60-1.18) for internalizing problems and 0.67 (0.38-0.95) for externalizing problems. The relative risk for children with asthma exceeding the 95% cut-offpoint for total problems was 4.2 (2.1-8.3) compared to healthy children. CONCLUSION: Children with parent-reported exercise-induced asthma symptoms were attributed more total problems than asthmatic children without such symptoms. Parent-reported day symptoms and child report of symptoms and restricted activities related with problem scores to a lesser degree. Objective measures of lung function and inflammation were not related to problem scores. Concurrent eczema increased problem scores. It is concluded that asthma in preadolescent children is associated with emotional and behavioural problems. Special attention should be paid to children reported to have exercise-induced symptoms.

Treatment outcome in subgroups of uncooperative child dental patients: an exploratory study.

OBJECTIVES: The principal aims of this study were to evaluate the treatment outcome in subgroups of uncooperative child dental patients and to test the validity of these subgroups, which were based on fear and personality characteristics. DESIGN: An exploratory, intervention study using quantified questionnaire, interview and observation data. SAMPLE AND METHODS: Eighty-six 4 to 12-year-old uncooperative child dental patients (of whom 81 were divided retrospectively into four subgroups) and their accompanying parents were followed up during treatment at a specialist paediatric dental clinic in Sweden. Treatment was based on behaviour management techniques, supported by nitrous oxide/oxygen sedation if necessary. At baseline, parents answered a questionnaire including questions on child dental and general fear, temperament and behaviour, and parental dental fear, emotional stress, locus of control, parenting efficacy and attitudes to dental care, some of which were repeated post-treatment. The treating dentist rated child behaviour according to the acceptance of a maximum of 14 treatment steps at each visit. RESULTS: Approximately 90% of all children managed to undergo the dental treatment. Child dental fear and parental emotional stress decreased during treatment. Externalizing, impulsive children showed lower acceptance. In fearful, inhibited children, integrated use of sedation appeared to facilitate acceptance. Validity of the subgroups characterized as 'fearful, extrovert, outgoing', 'fearful, inhibited' and 'externalizing, impulsive' was supported, while heterogeneity within the group of 'non-fearful, extrovert, outgoing' children made validation difficult. CONCLUSION: Fear and personality characteristics may serve as diagnostic aids when planning treatment of uncooperative child dental patients. Controlled outcome studies using differentiated treatment methods for children with different fear and personality profiles are needed.

Self-reported competencies and problems among Swedish girls with eating disorders and a control sample, using the youth self-report.

OBJECTIVE: To study self-reported competencies and problems in adolescent girls with eating disorders, anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS) compared to matched normal controls. METHOD: The Youth Self-Report (YSR) was completed by 211 girls between 13 and 17 years of age with eating disorders and 211 controls matched for age, sex, and geographical area. RESULTS: Girls with eating disorders scored lower on all competence scales and higher on most problem 'scales compared to controls. Type of diagnosis had no effect on competence scales, but BN-patients scored higher than AN- and EDNOS-patients on many problem scales. AN-bingers/purgers reported more problems than restrictors on somatic complaints, delinquent behaviour, and the externalizing dimension. DISCUSSION: We conclude that the YSR gives important information concerning self-reported competencies and concomitant symptoms of general psychopathology in eating disordered adolescent girls.

The Youth Self-Report (YSR) and the Depression Self-Rating Scale (DSRS) as measures of depression and suicidality among adolescents.

Two hundred and thirty-seven adolescents from a junior high school in a small community outside Göteborg, Sweden, completed the Youth Self Report (YSR) and the Depression Self Rating Scale (DSRS). Self-reported suicidality and biographical data were also recorded. The school doctor and nurse assessed the adolescents' somatic, psychological and behavioural problems using school health-records. The convergent validity of the YSR total problems scale and syndrome scales were tested against the DSRS. Discriminant validity was assessed by the two measures' ability to predict suicidality and school health problems. The Internalising (r = 0.65**) and Anxious/Depressed (r= 0.61**) syndrome scales of the YSR had the highest correlations with the DSRS. However, all YSR syndrome scales were significantly, though more modestly, correlated with the DSRS. Using stepwise logistic regression analysis, four YSR sub-scales [Social Withdrawal, Anxious/Depressed, Attention problems and Delinquency] predicted mild-severe self-reported depression (DSRS scores 12 and above). The YSR syndrome scales Anxious/Depressed and Delinquency predicted suicide ideation whereas the Self-destructive/Identity problem and Social Withdrawal (low scores) scales predicted Suicide attempts. The YSR Anxious/Depressed sub-scale and the DSRS total score seem to measure a similar dimension. However, the Anxious/Depressed and Selfdestructive/Identity problem scales were superior in predicting suicidality.

Self-reported competencies and problems among Swedish adolescents: a normative study of the YSR. Youth Self Report.

The aim of the study was to provide a standardisation of self-reported competencies and emotional/behavioural problems among Swedish adolescents, using the Youth Self-Report (YSR). The YSR was completed by 2522 adolescents aged 13-18 years, recruited from secondary and upper secondary schools in different regions in Sweden. The results showed that effects of gender and age were small but significant with girls scoring higher than boys on most problem scales, and 15- to 16-year-olds scoring higher than younger and older adolescents on the problem scales. Small effects were also found for residence as well as for parental SES. The correlations between internalising and externalising problems were 0.51 for boys and 0.49 for girls, whereas the correlation between competence and problem scores was low. We conclude that the individual variation in YSR-scores is much greater than can be attributed to factors such as gender, age, SES, or residential area. Consequently, the YSR has the potential to serve as an instrument for assessing individual adolescents' self-reported competencies and problems in Sweden. Given the almost orthogonal relation between self-reported competencies and problems, the competence scale is surprisingly little used in psychopathology research.

Validating the Eating Disorder Inventory-2 (EDI-2) in Sweden.

OBJECTIVE: To validate the Eating Disorder Inventory-2 (EDI-2) on a Swedish population by investigating differences between 1) young women with eating disorder symptoms (patients and non-patients), and normal controls and 2) patients with different eating disorder diagnoses, regarding symptom load and psychological characteristics. Another objective was to update EDI as a screening instrument METHOD: Patients (n=194) with DSM-IV confirmed eating disorder diagnoses (anorexia nervosa AN; bulimia nervosa BN; eating disorder not otherwise specified, EDNOS) were compared vvith each other and with randomly selected and matched controls consisting of young women with self-reported eating disorder symptoms (n=51) and women without such symptoms (n=188). RESULTS: In general, women vvith eating disorderproblems, whether or not they were patients, scored significantly higher on both symptoms and personality characteristics compared to normal controls. Patients with DSM verified eating disorders did not differ from women with self-reported eating disorders symptoms on body dissatisfaction, perfectionism and impulsiveness. Women with self-reported symptoms did not differ from women without symptoms on interpersonal distrust and maturity fears. Amongst the patient groups, BN patients scored highest, and AN patients lowest, on self-reported pathology. Most of the EDI-2 scales and all the three indexes had acceptable specificity and sensitivity. CONCLUSION: EDI-2 discriminates well between women with eating disorder symptoms and normal controls, but responses from patients with AN should be interpreted with care. The EDI-2 indexes are especially recommended for screening purposes.

Usefulness of a psychometric questionnaire in exploring parental attitudes in children's dental care.

In this methodological study we investigated the usefulness and reliability of a questionnaire designed to capture 4 aspects of parental dental attitudes: dental knowledge, child oral health behavior, perceived importance of dental related aims, and parental responsibility. The study was undertaken in a group of 140 parents of schoolchildren aged 8-12 years from four comprehensive schools in Sweden. Test-retest reliability, quantified by the intraclass correlation coefficient (ICC) or by Cohen's kappa, varied from acceptable to excellent for different aspects of the questionnaire. The knowledge and responsibility-taking sections were also answered by a group of dental experts who showed a high level of internal agreement. Expert profiles, to which the parental assessments could be compared, were created. Exploration of the 4 aspects showed that this group of parents commonly had a multifocal view on the etiology and prevention of caries. Correlations between their knowledge assessments and the assessments made by the expert group varied from moderately negative to strongly positive. The parents revealed a high degree of dental-related motivation and responsibility, particularly according to oral health behaviors. In conclusion, the results indicate that this 4-part psychometric questionnaire might be a suitable instrument in investigations of priority and responsibility-taking as new aspects of parental dental attitudes, along with dental knowledge and child oral health behaviors.

The Paediatric Asthma Caregiver's Quality of Life Questionnaire in Swedish parents.

With the Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), parents grade impaired activities (5 items) and emotional concern (8 items) from 1 to 7 regarding how much their own quality of life (QoL) has been affected by the disease of their child during the last week. The questionnaire was translated into Swedish. To test the feasibility and validity of the Swedish version, 71 asthmatic children and their families were approached. Sixty-one families (86%) participated. The mean age of the children was 8.7 y. Parental grading of symptoms (Spearman's rho = 0.637, p < 0.001), the asthma-specific QoL of the child (rho = 0.359, p = 0.002) and gradings of asthma from medical records (mild asthma median score 6.69, moderate 6.27 and severe 5.12, p = 0.001) were all related to overall PACQLQ scores. The sex of the child, the presence of other diseases related to allergy, peak flow rate (PEFR) and socio-economic level did not affect the scores. Lower scores in the emotional domain were seen in parents of children on steroids (p = 0.049). The distribution of scores was heavily skewed towards the positive end of the scale, leading to limited power to discriminate among parents of children with mild asthma. The instrument had good internal consistency and was well accepted by the parents.

A review of interventions in the parent-child relationship informed by attachment theory.

Bowlby's attachment theory has inspired a dramatic shift in the way we understand the development of the early relationship between infant and caregiver(s). Though almost all infants develop an attachment relationship to their primary caregiver(s), not all of them are able to use their caregiver(s) as a secure base or haven of safety from which to explore the world. Mary Ainsworth was the first to describe in detail the aspects of the caregiving system that are most important for the development of the attachment relationship. During the last decade several studies have started to evaluate the possibility that insensitive and perhaps even inadequate parenting can be effectively ameliorated by interventions. The present article sketches the theory behind attachment-based interventions and reviews the evidence for the effectiveness of such interventions. Finally, the article gives examples of successful preventive as well as therapeutic interventions.

Quality of life in childhood asthma: use of the Paediatric Asthma Quality of Life Questionnaire in a Swedish sample of children 7 to 9 years old.

To validate a Swedish translation of the Paediatric Asthma Quality of Life Questionnaire (PAQLQ) and to study determinants of asthmatic children's quality of life, seventy-one 7-9-y-old children and their families were approached. Sixty-one children (86%) participated, 36 boys and 25 girls: 11 children with mild, 40 with moderate and 10 with severe asthma. The mean age was 8.7 y. Most commonly restricted activities during the week preceding the investigation were running (74%), gymnastics (30%), walking uphill (26%), playing football (20%) and shouting (13%). Parental rating of symptoms (Spearman's rho = -0.40, p = 0.001), percentage of expected peak flow rate (PEFR) (rho = 0.30, p = 0.009) and physicians' grading (mild, moderate and severe asthma, p = 0.047) all correlated significantly with PAQLQ scores. Younger children reported more impairment of QoL, as did children of parents not sharing household. Sex or presence of eczema or rhinoconjunctivitis did not significantly affect the scores. Children suffering from food allergy scored less impairment of QoL. The instrument was easy to administer, was well accepted by the children and had acceptable internal consistency.

Mental health and social adjustment in young refugee children 3 1/2 years after their arrival in Sweden.

OBJECTIVE: To investigate the relative importance of various risk and protective factors for mental health and social adjustment in young refugee children. METHOD: Of 50 Iranian refugee preschool children who were first evaluated 12 months after arriving in Sweden, 39 were reevaluated in a follow-up study 2 1/2 years later. The effect of exposure to organized violence, age, gender, individual vulnerability, parental functioning, and peer relationships on the children's well-being and adjustment was investigated using multiple and logistic regression analyses. RESULTS: Exposure to war and political violence and individual vulnerability before traumatic stress exposure were important risk factors for long-lasting post-traumatic stress symptomatology in children. Mothers' emotional well-being predicted emotional well-being in children, whereas children's social adjustment and self-worth were mainly predicted by the quality of their peer relationships. CONCLUSIONS: The results underline the fact that refugee children's adaptation is the result of a complex process involving several interacting risk and protective factors. For many refugee children, current life circumstances in receiving host countries, such as peer relationships and exposure to bullying, are of equal or greater importance than previous exposure to organized violence.

Temperament and child dental fear.

PURPOSE: The relationship between dental fear and temperament in children was investigated in 124 Swedish children aged 5-7 and 10-12 years. They represented dentally fearful (65) and not fearful (81) children, and were drawn from a larger population-based patient pod. The aims of the investigation were to study the relationships between temperament on one hand, and dental fear and dental behavior-management problems on the other hand. METHODS: Dental fear was measured by the Dental Subscale of Children's Fear Survey Schedule (CFSS-DS) and the Children's Dental Fear Picture test (CDFP), while the Emotionality, Activity, Sociability (EAS) Temperamental Survey was used to assess four aspects of temperament: negative emotionality, shyness, sociability, and activity. RESULTS: Using Student's t test, children with dental fear had statistically significantly higher scores on shyness compared with normative data on EAS from Sweden. When fearful children were compared with the others in the study group by the use of Student's t test, children with dental fear scored statistically significantly higher on both shyness and negative emotionality. CONCLUSION: Thus, children expressing shyness and/or tendencies of negative emotionality should be considered patients at risk for developing dental fear problems.

Effects of day care on the development of cognitive abilities in 8-year-olds: a longitudinal study.

In Göteborg, Sweden, 146 children (72 girls) were enrolled in a longitudinal study when they averaged 16 months of age. None of the children had experienced regular out-of-home care yet, but within 3 months, 54 entered center care and 33 entered family day care. Quality of home and out-of-home care environments, child temperament, and the development of verbal abilities were assessed regularly during preschool years. When they were 8 years old (2nd grade), cognitive ability tests were administered to the 123 children (65 girls) still in the study. Tested ability was related to the number of months children had spent in center-based day care before 3.5 years of age. Child care quality predicted cognitive abilities among children who had spent at least 36 months in out-of-home care during their preschool years. Both tested and rated cognitive abilities in 2nd grade were related to earlier measures of verbal ability and to paternal involvement during preschool years.