A R T IC L E S
child appears to result in more fear-
related behaviors.
This study has begun to specify be­
havioral interactions during routine
treatm ent of young children. A d d i­
tional studies of other populations of
children, such as school-age children,
are needed. Moreover, the m ethodol­
ogy used in this study has the potential
to assess the effects of not only behav­
iors, but also pharm acological m an­
agem ent of patients. W hat is learned
from these studies may be of consider­
able benefit to both providers and den­
tal students. CT'aT',
This study was funded by grant no. 1 RO 1 DE
04770-01 from the N ational Institute for Dental
Research.
1. Forgione, A.G., and Clark, R.E. Com ments on
an em pirical study of the cause of dental fears. J
Dent Res 53:496, 1974.
2. Shoben, E.M., and Borland, L. An em pirical
study of the etiology of dental fears. J Clin Psychol
10:17-174, 1954.
Dentists’ responses to fear- and nonfear-related
behaviors in children
P. Weinstein, PhD
T. Getz, MS
P. Ratener, M S
P. Domoto, DDS, M PH
D entists m a y respond differen tly to fear- an d nonfear-related
behaviors in children, an d those responses m ay influence
the ch ildren’s further behavior. This study exam ines that
interaction.
r has led to studies designed to assess
h ild re n ’s behavior in the opera­
tory has alw ays been of concern in
dentistry. Children m ust cooperate or
m ust at least passively accept treat­
m ent so that the dentist can com plete
technical procedures. M elam ed and
associates1 found that the level of fear
38 ■ JADA, Vol. 104, January 1982
3. Lautch, H. Dental phobia. Br J Psychiatry
119:151-158, 1971.
4. Kleinknecht, R.A.; Klepac, R.K., and A lexan­
der, L.D. O rigins and characteristics of fear of
dentistry. JADA 86:842-848, 1973.
5. B ernstein, D.A.; K leinknecht, R.A.; and
Alexander, L.D.Antecedents of dental fear.J Pub­
lic Health Dent 39(2):113-124, 1979.
6. W einstein, P. Identifying patterns of behav­
ior during treatm ent of children. In Ingersoll, B.,
and M cKutcheon, W. eds. Proceedings of the Sec­
ond N ational Conference on Behavioral Dentistry:
Clinical Research in Behavioral Dentistry, Mor­
gantow n, WVa Univ of West Virginia Press, 1980.
7. Getz, T.; W einstein, P.; and Domoto, P. The
effect of structural variables on child behavior in
the operatory. Pediatr Dent, to be published.
8. Domoto, P.K.; W einstein, P.; and Getz, T. A
pilot study using remote broadcasting equipm ent
to provide instruction in pedodontics.J Dent Educ
4 3 (llptl):599-601, 1979.
9. W urster, C.A.; W einstein, P.; and Cohen, A.J.
Com m unication patterns in pedodontics. Percept
Mot Skills 48(1):159-166, 1979.
10. Glennon, B., and Weisz, J.R. An observa­
tional approach to the assessm ent of anxiety in
children. J Consult Clin Psychol 46:1247-1257,
1978.
11. Sackett, G.P. M easurem ent in observational
research. In Sackett, G.P., ed. Observing behavior,
vol II. Baltimore, Md, University Park Press, 1978.
experienced by the child was posi­
tively related to the degree of d isru p ­
tive behavior displayed during a re­
storative appointm ent. Moreover, re­
search2'4 suggests that traum atic den­
tal experiences lead to the develop­
m ent of fear, providing support for the
12. Sackett, G.P.; Stephenson, E.; and Ruppen-
thel, G.C. Digital data acquisition system s for ob­
serving behavior in laboratory and field settings.
Behav Res M ethods and Instrum entation 5:344-
348, 1979.
13. Sackett, G.P., and others. A fortran program
for lag sequential analysis of contingency and
cyclicity in behavioral interaction data. Behav
Res M ethods and Instrum entation, 11:366-378,
1979.
14. Howitt, J.W., and Strieker, G. Child patient
responses to various dental procedures. JADA
70:70-74, 1965.
15. Langer, E.J.; Janis, I.L.; and Wolfer, J.A.Re­
duction of psychological stress in surgical pa­
tients. J Exper Soc Psychol 11:155-165, 1975.
16. Johnson, J.E.Effects of accurate expectations
about sensations on the sensory and d istress
com ponents of pain. J Pers Soc Psychol 27:261-
275, 1973.
17. Averell, J.R.Personal control over aversive
stim uli and its relationship to stress. Psychol Bull
80:286-303, 1973.
18. Maccoby, E.E. Social developm ent. New
York, Harcourt, Brace, Jovanovich, Inc, 1980.
19. Bernstein, L.; Bernstein, R.S.; and Dana,
R.H. Interview ing: a guide for health profes­
sionals. New York, A ppleton-C entury-C rofts,
1974.
20. Rogers, C.R. On becoming a person. Boston,
Houghton Mifflin, 1961.
supposition that the process of provid­
ing care is at least as im portant as the
treatm ent outcome.
Most research on the m anagem ent of
children has been based on the tacit
assum ption that the child is the prob­
lem and that it is his or her behavior
that m ust be altered. This assum ption
the effect of interventions to m odify
the c h ild ’s behavior. Few studies have
hypothesized that m anagem ent prob­
lems may have an iatrogenic com po­
n e n t, and few have a tte m p te d to
exam ine how the dentist’s behaviors
influence treatm ent outcome.

Dentists most frequently respond to the child’s
fear-related behavior with those behaviors that are
counterproductive and ineffective in reducing fear:
rules, coercion, coaxing, reassurances, putdowns.
A pilot study by Wurster and as­
sociates5 examined communication
patterns during pedodontic appoint­
ments in a dental school setting. Six­
teen dental students were videotaped
during a restorative appointment with
a child. Markov analysis techniques
were u sed to ca lcu la te the prob­
abilities for the occurrence of specific
behaviors by the child after certain be­
haviors by the dentist. The prob­
abilities for the occurrence of specific
dentist behaviors after certain child
behaviors were also calculated so that
the pattern of behavioral interactions
would be clearer. Their results suggest
that child behavior is systematically
related to the communication style of
the practitioner, and that the behavior
of the dentist is influenced by the
child’s behavior.
A more thorough understanding of
dentist-child interactional patterns is
necessary. In a field study of private
p ra ctitio n ers, W e in ste in and a s­
sociates6 found that the incidence of
fear -and distress-related behaviors by
the child varied significantly after dif­
ferent behaviors by the dentist. This
paper describes the probabilities for
the occurrence of specific dentist be­
haviors after fear-related and nonfear-
related child behaviors.
Method
The m ethods used in this study are the
same as those described in the preced­
ing paper.
In this study, the conditional prob­
abilities for specific dentist behaviors
in each of the four dimensions follow­
ing fear- and nonfear-related child be­
haviors were compared. The signifi­
cance of the differences between den­
tist’s responses after the child’s fear
and nonfear behaviors was determined
by transforming the data into 2 scores
and determining the probability that
the differences were due to chance.
Seventy-two videotapes have been
analyzed, representing two sequential
appointments for 36 children. Detailed
Weinstein-Others : DENTISTS’ RESPONSES TO FEAR- AND NONFEAR-RELATED BEHAVIORS IN CHILDREN ■ 39
data analysis and results are available
from the authors.
Results
The dentists’ responses in the guid­
ance dim en sio n , im m ediately after
fear-related behaviors by the ch ild
(first lag), were less likely to be direc­
tion and reinforcement; whereas after
nonfear-related behaviors, the dentist
was more likely to use direction, and
reinforcement. The difference in the
d e n tis ts ’ re sp o n ses after fear- and
nonfear-related behaviors is statisti­
cally significant.
The probability that the dentist w ill
use rules, coercion, and coaxing was
g re a te r im m e d ia te ly after a c h ild
showed fear-related behaviors and de­
creased after nonfear-related behav­
iors. The difference in the probability
that the dentist w ill use rules and coax­
ing is significant.
In the second lag after fear-related
behaviors, the probability for the den­
tists’s use of reinforcement, rules, and
coercion was sim ilar to that of the first
lag. However, the only significant dif­
fe re n c e b e tw e e n th e d e n tis t’s re ­
sponses after fear- and nonfear-related
behaviors occurred for reinforcement;
again, the dentist was more likely to
use reinforcem ent after nonfear behav­
iors th an after fear behaviors. The
probability that the dentist w ould use
explanations, a frequent dentist behav­
ior, and rhetorical questions rem ained
unchanged after the c h ild ’s fear- and
n o n fear-related beh av io rs for both
lags.
For the first lag in the em pathy di­
mension, the conditional probability
Providing explanations, use of rhetorical questions,
and patting appear to be more a function of the
dentist’s interpersonal style rather than a response to
the child’s behavior.
ARTICLES
that dentists w ould use reassurance,
ignoring I denying, or putdow ns in­
creased significantly after the ch ild ’s
fear-related behaviors; w hereas the
pro b ab ility th a t the d en tist w ould
question for feeling decreased. Fol­
lowing the ch ild ’s nonfear-related be­
haviors, questioning for feelings in­
creased, w hile ignoring I denying de­
creased. Differences betw een the den­
tist’s responses to fear and nonfear be­
haviors are statistically significant for
all dentist behaviors except reassur­
ance. At lag 2, the probabilities for
questioning for feelings, reassurance,
ignoring I denying, and putdow ns in­
crease following fear-related behav­
iors by the child. Following nonfear-
relate d beh av io rs, th e co n d itio n a l
probabilities for all dentist behaviors
did not vary from the unconditional
probabilities. Differences betw een the
dentist’s responses to fear and nonfear
behaviors at lag 2 are significant for
reassurance, ignoring I denying, and
putdow ns.
In the first lag of the verbalization
dim ension, im m ediately following the
child’s fear-related behaviors, the den­
tist’s dental and nondental verbaliza­
tion to the assistant decreased signifi­
cantly, w hile dental and nondental
verbalizations to the child increased.
Follow ing nonfear-related behaviors
by the child, the dentist’s silence and
verbalization to the assistant increased
while verbalization to the child de­
creased. The dentist’s responses after
the c h ild ’s fear-related behaviors in
the verb alizatio n d im en sio n differ
significantly from the verbalization re­
sponses after nonfear-related behav­
iors for the first lag. At lag 2, following
child’s fear-related behaviors, the den­
tist’s silence or nondental verbaliza­
tion to the assistant decreased while
dental and nondental verbalizations to
the child increased. The differences in
the dentists’s responses to the c h ild ’s
fear- and nonfear-related behaviors are
significant for dentist silence and den­
tal and nondental verbalization to the
child.
AR TICLES
Direction, reinforcement, and questioning for
feelings have the highest probabilities of reducing
fear-related behaviors by the child.
In the physical contact dimension
after fear-related behaviors, the condi­
tional probability that the dentist w ill
be in physical contact with the child
increased for the first two lags. In the
first lag, working contact, holding, and
the use of restraint increased following
fear-related behaviors. Assistance in
p o sitio n in g decreased. F ollow in g
nonfear-related behaviors, the use of
restraint decreased, while assistance
increased. In lag 2, the probability of
the use of restraint increased following
fear-related behaviors.
Discussion
Dentists were less likely to use direc­
tion or reinforcement (guidance di­
mension) after the child’s fear-related
behavior. However, learning theory
suggests that ignoring or failing to
reinforce cooperation tends to lead to
an increase in uncooperative behav­
iors. This is supported by the results of
W einstein and associates that the
probabilities of child fear behaviors
decreased after the dentist uses direc­
tion and reinforcement.6 Dentists were
more likely to use rules, coercion, and
coaxing after child fear-related behav­
iors than after nonfear behaviors.
These behaviors were found in the
Weinstein study to be ineffective in
reducing the child’s fear behavior.
The probability for use of question­
ing for feelings, a behavior subcate­
gory of the empathy dimension, de­
creased immediately following fear-
related behaviors by the child, even
though W ein stein and asso cia tes
found that questioning for feelings is
relatively effective in reducing fear-
related behaviors.6 Use of the other be­
haviors in the empathy dimension in­
creased following fear-related behav­
ior, but it appears, as reported previ­
ously, that these forms of attention to
distress have little or no effect in re­
ducing the probabilities of fear behav­
iors by the child.
40 ■ JADA, Vol. 104, January 1982
As would be expected, when the
c h ild b e g in s to sh o w fear- and
distress-related behaviors, the den­
tist’s verbal and physical interactions
w ith th e c h ild in c r e a se d . C on­
sequently, dentist silence, noncontact,
and verbalization to the assistant de­
creased. Following nonfear behaviors,
verbalizations to the child decrease,
w hile verbalization to the assistant
and the amount of silence by the den­
tist increase.
Conclusions
In all, these data suggest that dentists
most frequently respond to the child’s
fear-related behavior with behaviors
that are counterproductive or ineffec­
tive in reducing fear: rules, coercion,
coaxing, reassurances, and putdowns.
Dentists less frequently respond with
behaviors such as direction, rein­
forcement, and questioning for feel­
ings, which have the highest prob­
abilities of reducing fear-related be­
haviors by the child.
Some dentist’s behaviors did not
vary under fear or nonfear conditions.
The behaviors that were invariant
were providing explanations, use of
rhetorical questions, and patting.
These appear to be more a function of
the dentist’s interpersonal style rather
than a management strategy or a re­
sp o n s e to th e c h ild ’s b e h a v io r .
Analysis of the dentist’s responses
clearly illustrated distinct differences
in interactional styles. Some dentists,
for exam ple, used em pathetic re­
sponses far more frequently than did
others. It may be that the range of a
particular dentist’s style varies only
slightly, irrespective of the behavior of
the child. Further investigations of
appointments with high and low fear
children treated by the same dentist
w ill be conducted to test this hypothe­
sis.
These findings, in conjunction with
our study of the efficacy of specific
dentist behaviors in affecting child
fear-related behaviors, present mean­
ingful patterns of dentist and child be­
havior in private practice. It appears
that at least two problems exist. First,
practitioners may not have the appro­
priate child management skills in their
repertoire. In a recent survey of Wash­
ington State private practitioners,
Domoto and associates7 reported that
only 48% of the sample received some
form of instruction in child manage­
ment when in dental school. Second,
though the practitioners may have the
necessary skills, they may not use
th e se s k ills w h en they are m ost
needed—w hen the child responds
with fear-related behaviors. Instruc­
tion, especially training w ith vid ­
eotape or remote broadcasting equip­
ment,8 may be extremely useful in add­
ing new skills or altering how existing
skills are used. ft
T his study was funded by grant no. 1 RO l DE
04770-01 from the National Institute for Dental
Research.
Dr. W einstein is associate professor and acting
chairperson, Mr. Getz is lecturer, and Mr. Ratener
is biostatistician, departm ent of com m unity den­
tistry, and Dr. Domoto is associate professor and
chairperson, departm ent of pedodontics, U niver­
sity of W ashington, Seattle, 98195. Address re­
print requests to Dr. Weinstein.
1. Melam ed, B.G., and others. Effects of film
m odeling on the reduction of anxiety-related be­
haviors in individuals varying in level or previ­
ous experience in the stress situation. J Consult
Clin Psychol 46(6):1357-1367, 1978.
2. Lautch, H. Dental phobia. Br J Psychiatry,
119:151-158, 1971.
3. Kleinknecht, R.A.; Klepac, R.K.; and Alexan­
der, L.D. Origins and characteristics, of fear of
dentistry. JADA 86:842-848, 1973.
4. M elam ed, B.G., and others. Reduction of
fear-related dental m anagem ent problem s w ith
use of film ed m odeling. JADA 90(4):822-826,
1975.
5. W urster, C.A.; W einstein, P.; and Cohen, A.J.
Com m unication patterns in pedodontics. Percept
Mot Skils 48(1], 159-166, 1979.
6. W einstein, P., and others. The effect of den­
tist variables on fear-related behaviors of young
children. J Dent Res 60(Special Issue A): 193,
1981.
7. Domoto, P.; W einstein, P.; and Getz, T. A
pilot study using remote broadcasting equipm ent
to provide instruction in pedodontics. J Dent Ed
43(11 pt 1): 599-601, 1979.
8. Domoto, P.; W einstein, P.; and Getz, T. Dif­
ficult children: experiences of 145 W ashington
State private practitioners. Pediatr Dent, to be
published.