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Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 199-205
Preferences and their correlation between children and their parents' attitudes towards non-pharmacological behaviour guidance techniques – A cross-sectional study

Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Chinthareddypalem, Andhra Pradesh, India

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Date of Submission03-Nov-2018
Date of Decision26-Nov-2019
Date of Acceptance22-Nov-2020
Date of Web Publication22-Nov-2021


Introduction: Dental treatment for children requires the use of behaviour guidance techniques (BGTs), which are used in the dental office to make children cope with dental treatment. Aim: Evaluate how children and parents felt towards BGTs used in a dental office, by attitude meter and to correlate them. Materials and Method: Children (200) from 7–17 years and their parents were selected randomly to participate in the study. Each child and parent was asked to watch four video scenes of live BGTs, which include Tell Show Do (TSD), Modeling, Reward system, and Hand holding. A questionnaire collected demographic data, and their expressive attitudes were assessed using Line of favour (LOF) scale and Kruskal-Wallis Test. Results: Most preferred BGTs for Group I was modeling, Group II Reward, Group III Tell Show Do, and Group IV was Modeling, with a mean score of 5.95, 6.04, 5.57, and 5.78, respectively. Gender wise preferences, 32% of boys and 34% of girls preferred modeling in Group I, whereas, in Group II, 20% of boys and 21% of girls preferred reward, respectively. Chi-square test revealed that there is no significant difference between the groups and gender for the preference of BGTs in Group I (P=0.893) and Group II (P=0.592). There was no significant correlation between preferences of children and their parents. Conclusion: Modeling was the most preferred BGT for primary school children and parents of High school children. A reward was the most preferred BGT for high school children. TSD was the most preferred BGT for parents of primary school children.

Keywords: Attitude meter, BGTs, children, Line of favour, non-pharmacological

How to cite this article:
Nirmala S, Inthihas S K, Aerpogu D, Subbareddy C R, Nuvvula S. Preferences and their correlation between children and their parents' attitudes towards non-pharmacological behaviour guidance techniques – A cross-sectional study. Indian J Dent Res 2021;32:199-205

How to cite this URL:
Nirmala S, Inthihas S K, Aerpogu D, Subbareddy C R, Nuvvula S. Preferences and their correlation between children and their parents' attitudes towards non-pharmacological behaviour guidance techniques – A cross-sectional study. Indian J Dent Res [serial online] 2021 [cited 2022 Aug 12];32:199-205. Available from:

   Background Top

Behaviour Guidance is a comprehensive, continuous method meant to develop and nurture the relationship between the child and the dentist, which ultimately builds trust and alleviates fear and anxiety.[1]

According to American Academy of Paediatric Dentistry the main goals of Behaviour guidance techniques are: to establish communication with the child and parent, alleviate the child's fear and anxiety, deliver safe, quality dental care and build a trusting relationship between the child, dentist, and parent; promote the child's positive attitude towards oral health.[2]

Visiting a dentist can easily evoke strong fear reactions and acute anxiety in some children, and even adults who have not had positive dental experiences. Children and adults may have similar feelings, but adults are typically more logical and often have developed positive coping skills over time.[3] Unlike adults, most young children express their opinions without social pressure.[4] Although some children are relaxed and cooperative in the dental treatment environment, some children demonstrate disruptive behaviour that makes treatment more difficult. Appropriate use of BGTs can improve the child's behaviour in subsequent visits.[5],[6]

   Introduction Top

Parents' attitudes toward BGTs and their acceptance trend through the past decades indicate a higher demand for the use of non-aversive and child-friendly BGTs.[7] Although relevant literature and clinical experiences observed support the apparent effectiveness of BGTs, the justification of carrying out such a study is needed. Hence this study was conducted as no available scientific data are reporting the effectiveness of these techniques from a parental as well as childs' perspective.


It hypothesized that children and parents would like the BGTs that looked natural, positive, informative, or the least intimidating.

Aim of the study was

  1. To evaluate how children and parents felt towards the BGTs used in a dental office, by using an attitude meter.
  2. To assess the correlation between children and parents preferences.

   Materials and Method Top

This study was a cross-sectional study. Ethical clearance was taken from Institutional review ethical board. Prior to the study, consent obtained from the parents and assent from children. Sample size calculations were done based on the assumption that a 1.2 difference (6.2 versus 5.00) in a mean of Line of Favour would represent a clinically significant difference. A sample size of 100 children per group is a minimum required sample to detect an effect size of 1.2 in the primary outcome (LOF), as statistically significant with 82% power and at a significance level of 0.05 (two-tailed significance). Sample was calculated using IBM SPSS Sample Power Program version 3.0.1.

Four hundred children aged 7–17 years and their parents were selected randomly to participate in the study, and their demographic data recorded. The sample was equally divided into four groups:

Group I: Children of 7–11 years (primary school)

Group II: Children of 12–17 years of Adolescents (High school)

Group III: Parents of Group I children and

Group IV: Parents of Group II children

Inclusion criteria

For participation of parents were parenthood, literacy, enthusiasm to participate and ability to view the videotape

For participation of children were able to watch videotapes and communicate effectively

Exclusion criteria: Children with physical or mental disabilities.


Measurement of attitudes:

Parents of selected children were provided with a detailed explanation of the aim of the study and their consent for approval regarding their child's participation. All the parents were made aware that the AAPD approved all the BGTs used for evaluation.

Filmed videotapes of behaviour guidance techniques prepared in local language and used in the study were TSD, Modelling, Hand-holding, and Reward shown to children and parents separately. The authors selected BGT's as they are widely accepted. All BGT videotapes were viewed and evaluated by three trained paediatric dentists. Each 17-minute-videotape contained an introduction, including the aim of the study and the nature of using BGTs in clinical practice. Instructions were given only once at the beginning of video, followed by 30-second examples of each BGT videotape with pauses after each BGT for the parents and children. 'Line of favor' (LOF) designed to measure the attitude of the children toward each BGTs. Initially, a classic visual analogue scale (VAS) assessed the participants attitudes towards the BGTs. Therefore, the LOF was formulated and utilised to obtain the expressive attitude of the children, since it was simple for them to express how much they liked it [Figure 1]a. LOF was modified from VAS.
Figure 1: (a) Line of favor sheet. The distance between the anchor point to the right end of the sheet is 10 cm. (b) The length of the line of favor reflects the attitude towards the behaviour management technique

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The distance between the left anchor points to the right end of the paper is 10 cm [Figure 1]b. Children were asked to draw a line from the anchor point to the right. The attitude is depicted by the length of the line measured in a horizontal dimension in centimetres with one decimal point [Figure 1]. The length of the line mirrored how much they liked the BGT. Drawing a long line would express that they liked that BGT very much. On the other hand, if they were not very fond of that BGT, they would draw a very short line. The maximum length of the Line was 10 cm for the maximum score of liking or superior attitude. The arbitrary cut-points were 3 cm and 7 cm to the right of the anchor point. Even though 'liking' something is a continuous variable, the authors needed cut points to decide how to interpret the children's responses. Liking something less than 30% would somewhat reveal a negative attitude towards that particular thing and the opposite for liking something more than 70%. A score of:

  1. 0 to ≤3 cm indicates that a child is not very fond of that technique
  2. >3 to ≤7 cm indicates that the child neutral toward that technique
  3. >7 to ≤10 cm means the child likes that technique very much.

Statistical analysis: Descriptive statistics were performed to draw the percentages of most preferred techniques, parents and children's demographic data. Chi-square test and Kruskal-Wallis test was performed for evaluating intergroup correlation and preferred BGTs

   Results Top

The mean age of participants for Group I was 8.68 years, 12-17 years for Group II, 32.14 years for Group III, and 38.26 years for Group IV.

For group 1, the most preferred technique was modeling (5.95), and the least preferred technique was hand holding (4.60), whereas in Group II, Reward (6.04) and Handing holding (4.94), respectively [Table 1].
Table 1: Descriptive and inferential statistics of all the Four Groups

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For group III, TSD (5.57) was most preferred, and reward (5.32) was least preferred, whereas in group IV, Modeling (5.78) was most preferred and hand holding (5.21) was least preferred respectively. Also, hand holding was least preferred among all the groups except Group III, where Reward was least preferred [Table 1].

Gender wise preferences, 32%, Boys and 34% of Girls preferred modeling in Group I [Table 2] whereas, in Group 2, Boys (20%) and Girls (21%) preferred reward, respectively [Table 3]. Chi-square test showed that no significant difference between the groups and gender for the preference of behaviour guidance technique Group I (P = 0.893) and Group II (P = 0.592).
Table 2: Gender wise preferences of Group I (7-11 yrs)

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Table 3: Gender wise preference of Group II (12-17 Years)

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In Group III and Group IV, only mothers were interested in participating in the study. A total of 200 mothers ranged from ages 28 to 46 years. While among females, the most preferred techniques in Group III were in the order of TSD (5.57). Modeling (5.40), hand-holding (5.37), reward (5.32), whereas in Group IV was modeling (5.78), TSD (5.67), reward (5.32) and hand-holding (5.21), respectively.

There is no significant difference between groups for the preference of TSD (P=0.644).

   Discussion Top

Behaviour guidance is a continuum of skills employed by dentists to elicit cooperation from young and anxious children.[8] The American Academy of Pediatric Dentistry (AAPD) summarises process of communicative guidance, such as tell-show-do (TSD), voice control, non-verbal communication, positive reinforcement and distraction; other basic BGTs are parental presence/absence, memory restructuring and nitrous oxide/oxygen inhalation. Advanced BGTs include protective stabilisation, sedation and general anaesthesia (G.A.).[9] The importance of parental approval of these different techniques has risen dramatically over the years. Although, there have been studies on parental attitudes towards the behaviour guidance techniques used in paediatric dentistry. These studies determined how parents felt about behaviour guidance techniques used to manage their children in the dental setting.[10],[11] Nevertheless, children's perception of various aspects of the dental environment and their willingness to accept dental treatment is far more critical to achieve successful treatment. Few studies stated that children have strong preferences regarding the appearance of their dentist and dental clinics, which enhances a positive dental attitude in their mind and decreases anxiety. Few studies have discussed children's views of different behaviour guidance techniques.[12],[13]

As the dentist–child–parent relationship seemed to move from an authoritative to a supporting position giving children and parents the right to be involved in their treatment options,[14] this study aimed to evaluate their attitude towards different non-pharmacological behaviour guidance techniques adopted by the AAPD using line of favour. It is used to measure children's attitudes, which was developed by Kantaputra[15] that allows young children to convey their feelings regarding the various BGTs. They found that this attitude meter measuring scale is a reliable and easy tool to convey the children's feelings regarding the various behaviour guidance techniques.[15]

In the current study, LOF was used to measure the attitudes of children as other studies use it. The age group of children was similar to the study done by Kantaputra et al.[15]

Paediatric dentists provide oral health care and treat dental diseases in infants, children, adolescents, and persons with special health care needs. Safe and effective treatment often requires the management of the child's behaviour. Uncooperative or disruptive behaviour can interfere with the quality of care, increase the length of treatment time, and increase the risk of injury to the child. The acceptability of BGT depends on factors related to the child's need, the type and urgency of treatment.[16],[17]

Dental fear is a common, constituent and unavoidable emotion that appears as an outcome to the stress evoked by various dental procedures. Its intensity changes from nervousness and anxiety to dental phobia, and it is considered a significant factor for successful completion of treatment[18] modeling is another non-pharmacological technique described by Bandura. It is a process of acquiring behaviour through observation of a model. Greenbaum and Melamed reported that the first study of modeling, in paediatric dentistry conducted in 1969, and few studies followed in the 1980s.[19],[20],[21]

According to the studies, two forms of modeling, live, and recorded, are effective in reducing children's fear and anxiety of dental treatments and promoting adaptive behaviour.[22],[23],[24] The idea behind modeling is that one person's behaviour can be changed due to observing another person performing a given behaviour.[25] Modeling in other health settings has been well studied,[26] and research has demonstrated that children can also benefit from viewing other children or their parents undergoing dental treatment without fear reactions.[26],[27],[28] Modeling can be done live using a parent or significant other person in the child's life.[29]

Children who have had negative experiences coupled with medical treatment may be more anxious about dental treatment.[30],[31],[32] The Modeling technique is based on the psychological principle that people learn about their environment by observing others' behaviour, using a live model,[33],[34] to exhibit suitable behaviours in the dental environment.

Modeling technique is based on the Social Learning Theory in which the importance of observing and imitating behaviours, attitudes and emotional reactions of others is emphasized. The adage rightly goes that modeling allows 'learning without performance'.[24] Social learning theory predicts that fear response patterns in children can be extinguished by observing a model undergoing the feared stimulus without experiencing negative consequences.[24],[25] In the present study, most preferred BGT among Group I children was modeling, this finding is correlating with other studies.[35],[36]

Studies suggested that the practitioner must recognise the importance of parental influence upon the thinking as well as the behaviour of the child.[37],[38],[39] Sermet and Shaw[40] provided further clarification as they positioned the parent as pivotal in a child's acceptance of dental care. Peretz and Zadik[5] reported the preferences of parents, who observed the BGTs employed on their children, toward the dentists' approach. When children do not cooperate, 56% of the parents preferred their children to be relaxed by explanation, whereas only 20% voted for sedation after explanation and 6% for firmness after explanation.

In the present study, in Group IV, parents of high school children also preferred modeling which was consistent with a study done by Saleh Muhammed 2011[41], which reported that non-pharmacological techniques like modeling were very effective and this could be attributed to other factors which change over time like social attitudes, parental expectations, developing children's rights, and technology. Modeling helps in reducing children's fear and anxiety based on the psychological principle that children learn by observing others' behaviour, using a model either live or by video to exhibit appropriate behaviour.

A study by Farhat-Mchayleh, et al.[35] found that children who received live modeling with the mother as a model had lower heart rates than those who received live modeling with the father as the model and those who were prepared by the tell–show–do method. Sharma A. and Tyagi R.[41] also reported that techniques like live modeling and tell show do are very effective in modifying child behaviour.

A reward is an effective technique to reward desired behaviour and strengthen the recurrence of those behaviours.[42] In the present study, reward was preferred BGTs among adolescents (Group II) which was in accordance with other studies done by Kantaputra et al.[15] Davies and Buchanan et al. 2013[37] reported that children highly perceived reward in their research. This finding is correlating with present study where Group II children preferred reward and suggested that it may enhance positive dental attitude as well as promote future attendance. The older children have the experience to make decisions when compared to younger children. Children's opinions should always be taken seriously as they are the ones receiving the treatment.

It also found that in some aspects, adolescents thought differently than elementary students. It supports the concept that high school students 12–17 years old are in Piaget's formal operational stage of thinking, can see new kinds of logical relationships, and are more abundant in their conceptual abilities. These adolescents have more proficiencies at logical and abstract thought. May be this was what the elementary students in Piaget's concrete operational stage did not have making them think differently.

'Tell show do', which consists of explaining and demonstrating the operation of the instruments used during treatment, remains the most commonly used technique in paediatric dentistry.[13],[37],[42],[43],[44],[45]

Many children perceive a visit to the paediatric dentist as stressful. This could be expected because an appointment includes several stress-evoking components, such as meeting unfamiliar adult people, the attire worn by the clinicians, having to lie down, strange sounds and tastes, discomfort, dental injections, and pain. It should also be noted that children comprise a group of individuals representing a large variation in age, competence, maturity, personality, temperament and emotions, experience, oral health, family background, culture, etc.

A study by Murphy et al.[45] assessed the attitudes of parents toward behaviour management techniques employed in paediatric dentistry. Sixty-seven parents viewed videotaped segments of the actual treatment of three- to five-year-old children. He concluded that the majority of parents favoured tell-show-do. The least acceptable techniques were general anaesthesia and papoose board.

Another study by Boka et al.[12] examined the acceptance by Greek parents of nine behaviour-management techniques and its association with several possible confounding factors. After being shown a video with nine behaviour management techniques, parents rated acceptance of each technique on a 0–10 scale. The best-accepted technique was to tell–show–do. The very high rating found for tell–show–do was expected, as it is among the safest and least invasive behaviour-management techniques, and its acceptability appears relatively stable over time.

Other study by Eaton et al.[44] conducted a study on parental attitudes toward behaviour management techniques currently used in paediatric dentistry. Fifty-five parents viewed videotaped scenes of 8 behaviour management techniques and rated their acceptance of each technique using a visual analogue scale (VAS). He concluded that tell-show-do rated as the most acceptable technique by the parents.

Another study by Luis de León et al.[45] examined the attitude of a group of Spanish parents towards behaviour-management techniques videos with different behaviour-management techniques shown to 50 parents whose children were treated at the International University of Catalonia (Barcelona, Spain). The techniques shown were as follows: tell-show-do, nitrous-oxide sedation, passive restraint, voice control, hand over mouth (HOM), oral premedication, active restraint and general anaesthesia. Parents gave an acceptance rating of each of these techniques according to a scale of 0 to 10, with 0 being the lowest level of acceptance and 10 the highest. He concluded that parents preferred the Tell show do technique.

Another study by Peretz B, Zadik D[5] investigated the attitudes of 104 parents toward behaviour management techniques used during the dental treatment of children. The techniques for managing children's behavior explained to parents before treatment, and parents were present in the operatory during dental treatment. At the end of the second appointment, parents completed a questionnaire requesting demographic, behavioral, and dental information as well as the parents' attitudes toward the management techniques. Most parents preferred an explanation as to the proper approach for treating their children. Voice control was accepted by most parents, Papoose Board, by one-third of the parents and physical restraint by nearly one-fourth of the parents. Of the parents who were in favor of restraint, most children did not cooperate. He concluded that explanations and witnessing children during dental treatment might raise parents' tolerance level to firm techniques. The technique rated as most acceptable was the tell-show-do technique, while the least accepted was the HOME technique. The current study also confirmed the previous finding regarding Tell show do, which was preferred by Group III, parents of the primary school children. Parents remarked that would enable the dentist to explain the procedure to the child using a simple language that the child could understand. Almost all the parents agree that it was essential to use various BGTS to achieve successful dental care for their children. Tell-Show-Do is a stable or constant outstanding acceptability. Parents demand for safer and less aggressive techniques is consistent with an increasing emphasis on children's rights.[13],[25],[28]

Hand-holding is a technique where the dentist and dental assistant actively immobilize the disruptive child by holding the child's head, hands, and body.[46],[47] In this study, parents of Primary school children (Group III) preferred hand holding over other BGTs. This finding is similar to the other study conducted by Kantaputra et al.[15] who concluded that the older children preferred hand-holding. This may be due to as the parents felt that it could prevent jerky movements during dental treatment; hence, they are more secured. On the contrary, Primary school children did not prefer hand holding over other BGTs. This may be due to as the children appeared to judge a behavior guidance technique according to its appearance.

   Conclusion Top

The following conclusions drawn from the study

  1. Modeling was the most preferred BGT for primary school children and parents of high school children.
  2. The reward was the most preferred BGT for high school children.
  3. TSD was most preferred BGT for parents of Primary school children
  4. There was no significant correlation between the preferences of children and their parents

We recommend that an adequate explanation of the various BGTs should be carried out, and the dentist must exercise good judgment in the choice and application of the most appropriate techniques in the management of both the child and his parents. It is essential to continuously reevaluate parental acceptance of BGT's to maintain optimal dentist-parent communication. There is a clinical relevance to this study's outcome, as it is better to know how children and their parents feel about what we do and also to understand the way they respond to the particular technique. Successful behavior guidance enables the dentist to perform the quality treatment and promote a positive attitude in the child.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Dr. S.V. S. G. Nirmala
Professor, Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_817_18

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