CONTINUING EDUCATION

Psychological inuences on the timing of

orthodontic treatment
Alice W. Tung, BS,
a
and H. Asuman Kiyak, MA, PhD
b
Seattle, Wash.
Debates about the ideal timing of orthodontic treatment have focused on issues of biologic
development and readiness. In this article we examine psychologic issues that should be
considered in the decision to initiate orthodontics in the younger child or to wait until adolescence
or later. Psychologic development during the preadolescent and adolescent stages may inuence
the childs motive for, understanding of, and adherence to treatment regimens. Results of a study
of some personality characteristics, motives, and aesthetic values of young phase I patients are
presented. Questionnaires were completed by 75 children (mean age 10.85 years, 52.1% female,
84% white) and their parents. Childrens perceived reasons for treatment were consistent with their
parents reports (
2
76.08, p .001); most were referred for crowded teeth (56%) and overbite
(17.3%). Although body image and self-concept scores were within the normal range, both children
and their parents expected the most improvement in self-image and oral function, with greater
expectations by parents on self-image (p .0001), oral function (p .0001), and social life (p
.03) than children themselves. Although white and minority children were similar in their self-ratings
and expectations from orthodontics, the former were more critical in their aesthetic judgments.
They rated faces with crowded teeth (p .02), overbite (p .02), and diastema (p .01) more
negatively than did ethnic minorities. These results suggest that younger children are good
candidates for Phase I orthodontics, have high self-esteem and body-image, and expect orthodon-
tics to improve their lives. White children who have been referred for Phase I orthodontics appear
to have a narrower range of aesthetic acceptability than minority children. (Am J Orthod Dentofacial
Orthop 1998;113:29-39.)
Facial aesthetics has been found to be a
signicant determinant of self and social percep-
tions and attributions.
1,2
These perceptions of facial
aesthetics inuence psychological development
from early childhood to adulthood. The infants
visual preference for human faces has been con-
rmed in many psychological studies.
3
This behavior
is adaptive; recognition of familiar faces is critical
for an infants survival. By the age of 6 months,
children can discriminate between familiar and un-
familiar faces.
4
By the age of 6 years, children have
internalized cultural values of physical attractive-
ness. By age 8 their criteria for attractiveness are the
same as those of adults.
5
A teachers perceptions of
a childs attractiveness can inuence the teachers
expectations and evaluation of the child.
6
Similar
results were found in a study conducted in Nigeria.
7
Children perceived as more attractive are not only
more socially accepted by their peers, they are also
believed to be more intelligent and to possess better
social skills.
3,8-11
In addition, people perceived as
attractive by their peers are considered more desir-
able as friends than are unattractive people.
3
Em-
ployees perceived as more attractive by their super-
visors are given better job-performance ratings than
less attractive employees.
12
Thus, individuals who
are perceived by their parents, peers and employers
to be attractive are more likely to experience posi-
tive social interactions and evaluations. Studies of
laypersons responses to attractive and unattractive
faces of strangers have shown that attractive persons
are described as more competent in interpersonal
relationships and friendlier than people with unat-
tractive faces, even when the test subjects had no
additional knowledge about the faces being exam-
ined.
13
The Role of Teeth in Appearance
The appearance of the mouth and smile plays an
important role in judgments of facial attractive-
ness.
14
This nding is consistent with the results of
two previous national surveys that showed most
Americans believe dental appearance is very im-
From the Department of Oral and Maxillofacial Surgery, University of
Washington.
a
Dental student.
b
Professor of Oral and Maxillofacial Surgery.
Ms. Tung was supported by a University of Washington Summer Research
Fellowship, NIDR grant T35-DE07150.
Copyright 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 0 8/5/86269
29
portant in social interactions, particularly in young
peoples selection of dating partners.
15,16
Children of
normal dental appearance are judged to be better-
looking, more desirable as friends, and more intel-
ligent.
17
Children have reported that the appearance
of their teeth is a common target of teasing.
18
In
particular, malocclusions in the anterior region are
the most conspicuous and raise the childs greatest
concerns.
19-21
Helm and colleagues have found that
overjet, extreme deep bite and crowding are associ-
ated with the most unfavorable self-perceptions of
teeth.
19
Shaw has found that an overjet of 7 mm or
more, anterior crowding and deep bite are associ-
ated with a childs report of being teased.
17,18
Over-
jet has also been found to be the most signicant
predictor of the decision to seek orthodontic correc-
tion, especially in children referred for treatment by
their parents.
20
Some researchers have examined laypersons
evaluations of malocclusions in terms of attractive-
ness. The following classes have been ranked from
most to least attractive: Class I, open bite, Class II,
and Class III,
22
but patients with Class II malocclu-
sion have been found to be signicantly more moti-
vated to seek treatment than Class III patients.
23
Contrary to the ndings of these studies, which
comprised mostly white patients, research with
Asian subjects has revealed a different pattern of
perceived dental attractiveness of malocclusion
types. A study in Singapore revealed that Class III
malocclusion is ranked as more attractive than Class
II.
24
Malocclusions consisting of overjet, deep bite
and overcrowding have been associated with the
most negative self-evaluations among Danish
adults.
19
This self-perception of dental aesthetics
has been suggested as the most common predictor
of the seeking of treatment.
20,25,26
Perceived facial
appearance has also been found to be an important
predictor of the decision to undergo facial surgery
for improvement of dental appearance.
6
Perceived need for treatment does not necessar-
ily reect an individuals actual clinical need as
assessed by an orthodontist.
27
The demand, or self-
perception of need, for orthodontic treatment is
greater in female subjects than in male sub-
jects,
24,27,28
among white subjects, in urban settings
and among children of higher socioeconomic status.
In contrast, actual clinical need was found in these
same studies to be greater for males and whites and
equal across socioeconomic strata and in urban vs.
rural settings.
27
In Asian subjects the perceived need
for orthodontic treatment has been found to be
inversely correlated with the rank order of maloc-
clusion attractiveness.
24
In descending order of at-
tractiveness ratings, children with Class I, open bite,
Class III, Class II, anterior crowding, and deep bite
ranked themselves as increasingly more likely to
need treatment.
Self-Concept and Appearance
The individuals interactions with and responses
from others may inuence the development of self-
concept.
6
Self-concept is dened as the perception
of ones own ability to master or deal effectively with
the environment.
29
Developmental psychologists
generally agree that a childs self-concept develops
from the reected appraisal that he or she re-
ceives from others.
30
In other words, self-concept is
affected by the reactions of others toward the child.
Self-concept also depends on social comparisons
and self-attributions by the child. Fig. 1 illustrates
the variety of factors that inuence self-concept. It is
important to note that researchers have consistently
found that self-concept is related more to the indi-
viduals perceptions of others evaluations than to
objective evaluations by others.
3,30
As discussed
earlier, facial attractiveness plays an important role
in social acceptance by peers. A positive relationship
also exists between physical/facial attractiveness and
interpersonal popularity, as well as others favorable
evaluations of personality, social behaviors, and
intellectual expression.
31
Females have consistently been found to have
more negative body image and self-concept scores.
This phenomenon begins in adolescence, when girls
become more concerned about their physical ap-
pearance and weight. Although pubertal changes
increase the self-consciousness of boys and girls, the
Fig. 1. Social factors affecting self-concept.
American Journal of Orthodontics and Dentofacial Orthopedics
January 1998
30 Tung and Kiyak
latter are more inuenced by these rapid changes in
their physical appearance, and they continue to
attach more importance to these external character-
istics into adulthood.
32-34
Parental concern most likely stems from the
parents hope that the child will conform to their
own and societys ideals of facial attractiveness.
35
It
has been suggested that parental inuence based on
dental aestheticsnot necessarily malocclusion se-
veritymay be the main motivating factor for chil-
dren to seek orthodontic treatment.
36
These ndings
are similar to those of Dann and colleagues
37
; the
degree of malocclusion does not affect the decision
to undergo treatment as much as the perceived
aesthetics of the malocclusion.
Although overall self-concept has not been
found to be altered by orthodontic treatment, some
components of self-concept, perceptions of appear-
ance by others (e.g., parents and peers), and body
image have been found to improve after treat-
ment.
1,6,34
In children with more conspicuous facial
impairments such as cleft lip or palate, correction
may result in improved school performance and
social acceptance.
38,39
Treatment During Preadolescence or
Adolescence?
The decision of whether to treat a patient in
childhood or adolescence raises several issues re-
lated to the developmental stages of preadolescence
and adolescence.
40-42
One of these issues is the
concern with adherence. Treatment adherence is
inuenced by a childs sex and age. In general, girls
are more likely to adhere to treatment recommen-
dations than boys.
40,41
Preadolescent children have
been found to be more adherent to rules for the use
of removable appliances than adolescents.
41
For this
reason it has been suggested that treatment begin
after age 6 and be completed before the onset of
puberty.
41
Other predictors of greater adherence
include high self-esteem, optimism regarding the
future, and low social alienation.
40
Children experi-
ence major changes in these aspects of the self as
they move from early childhood through the teen
years.
According to Eriksons theory of psychosocial
development,
43
the preadolescent experiences the
stage of industry vs. inferiority when social and
academic skills develop, children begin to compare
their capabilities in these areas with peers, and they
increasingly recognize that they can achieve compe-
tence through their own initiative. The adolescent
goes through a period of identity vs. role confu-
sion, Eriksons fth stage of psychosocial develop-
ment. This is a period of role confusion for many
adolescents as their physical selves mature into their
future adult selves yet they are still treated as
children. The goal of this developmental stage is the
search for identity, or a feeling of being at home in
ones body, a sense of knowing where one is going,
and an inner assuredness of anticipated recognition
from those who count.
43
Adolescence is often associated with increased
self-consciousness, confusion about identity and ac-
ceptance by others, and concerns about recognition
from adults and peers. Younger children are inu-
enced greatly by their parents and other adults (e.g.,
teachers, health care providers). As the child enters
adolescence, however, peers assume a greater role
in their lives, especially in terms of self-image.
3
Peers often serve as a standard of comparison and
implicit or explicit critics of the adolescents appear-
ance, dress, activities, and interests. The ambiguity
and uidity of these peer relationships and the
reliance on peer acceptance and ambivalence about
parental authority can lead to social alienation but
can also provide adolescents with important chal-
lenges that help them achieve a sense of identity or
inner assuredness. Indeed, the social, emotional,
and, often, academic crises of adolescence are
viewed by some personality theorists as a healthy
process of reconstructing ones identity and self-
concept.
43,44
Other developmental psychologists
have found that self-concept does undergo some
changes during adolescence but that these changes
are not necessarily traumatic.
45,46
The increasing signicance of peer acceptance
for adolescents results in greater need for social
comparison. Girls in particular express greater con-
cern about their facial features, especially when
certain features (teeth, nose, hair) are different from
those of their peers. Boys are not immune to the
social-comparison process, but they are more likely
to express concerns with their athletic ability and
physical size compared with their peers. This in-
creased focus on the self relative to his or her peers
may help or hinder the childs success with ortho-
dontic interventions. If the adolescent has signi-
cant concerns about the appearance of his or her
teeth and has friends who are undergoing or have
undergone orthodontics, they can serve as role
models for the child. This role-modeling can result
in greater cooperation with the treatment regimen.
If, however, the child is absorbed in other develop-
mental tasks of adolescence, it may be the wrong
time to initiate treatment. Research by Peevers
47
on
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 113, No. 1
Tung and Kiyak 31
childrens past, future, and current perspectives, and
their perception of change vs. constancy in themselves,
provides further evidence that adolescence is a time of
identity confusion. Using a qualitative methodology,
Peevers analyzed self-descriptions of children aged 6,
9, 13, and 17 years. Childrens descriptions of their
lives were coded in terms of continuity (past, present,
future orientation), distinctness of the self as a unique
being, and self-reection. Distinctness was least evi-
dent at age 6 and most evident at ages 9 and 13.
Self-reective descriptions did not emerge in children
until age 17. Fig. 2 illustrates age differences in chil-
drens time orientation, or their perceptions of them-
selves as having a past, present, and future. It is evident
that adolescents in this study focused most on their
past selves, least on their future. Yet they were more
likely than the younger subjects to perceive changes in
themselves since early childhood (e.g., Since middle
school, Ive changed a lot in my personality). In
contrast, the 6- and 9-year-olds were more likely than
adolescents to think of their future selves (e.g., I hope
someday Ill become an artist) and to view themselves
as having experienced few changes in their lives and in
their personalities so far. These differences may have
implications for childrens attitudes toward, and adher-
ence to, orthodontic treatment. Adolescents focused
on the here and now may have more difculty with
long-term adherence in the interests of future im-
provements in their oral function and appearance.
Description of Current Study
To determine whether younger children referred
for Phase I orthodontics are prepared from a devel-
opmental perspective, we conducted a study of such
children and their parents. We administered a ques-
tionnairedesigned to assess self-concept and body
image, ability to dene the orthodontic problem for
which they had been referred, and their expectations
from treatmentto children. Parents were included in
the study to obtain factual information about the child
and treatment decisions, as well as their perceptions of
treatment need and the childs level of self-care. This
study was therefore an attempt to explore some of the
issues of child development that have been raised as
potential barriers to Phase I treatment.
Although some orthodontists are concerned that
the younger child is not psychologically ready for
treatment and that the parent of a younger child
plays a greater role in the decision and treatment
phases than with adolescents, these concerns may be
alleviated by the recognition that younger children
are generally aware of their malocclusion, con-
cerned about improving it, and less burdened with
the stresses of adolescence described above.
MATERIAL AND METHODS
Sample
The sample comprised children ages 9 to 12 years in
fourth or fth grade in three Seattle-area schools and
children in the same age range who had been examined by
an orthodontist in Anchorage, Alaska. To control for the
effects of socioeconomic status and location, we ensured
that the children were representative of middle- to upper-
income groups in these communities. A total of 160
parents were contacted from one public and two private
schools in Seattle through the principal or vice principal of
each school. In the Anchorage area, parents of 37 children
were contacted by an orthodontist who had screened these
patients in the preceding 2 years. These families were sent
a letter describing the purpose of the study and asking
them to return an attached postcard with the following
questions: (1) Had the child ever received a recommen-
dation to undergo early orthodontic treatment? (2) Had
the child undergone the treatment, or was he or she
currently in treatment? and (3) If the treatment was
recommended, would the child and parent be willing to
complete questionnaires regarding their decisions?
One hundred forty-eight postcards were returned
(92.5% response rate); 98 of these children had been
referred for orthodontics and were willing to participate in
the study. Among the remainder, 31 had never been
referred for treatment and 9 had been referred but did not
want to participate in the study. Packets containing ques-
tionnaires for one parent and the subject child were
mailed to the 98 families who expressed interest in the
study. Parents and children in this group also were sent
institutional review boardapproved consent forms for the
parent and an assent form for the child. The cover letter
Age (years): 6 9 13 17
Past: 33 54 73 59
Future: 22 29 4 22.5
Change: 0 0 11.5 13
No Change 45 17 11.5 5.5
*Summarized from Peevers (1987)
47
Represents percentage giving response with this time perspective.
Fig. 2. Time orientation of children (%).
American Journal of Orthodontics and Dentofacial Orthopedics
January 1998
32 Tung and Kiyak
to each parent indicated that the child would receive $5 if
they both returned the two completed questionnaires.
One month after the packets were mailed, reminder
postcards were sent to those who had failed to respond.
Two weeks later, a second postcard was mailed to families
who had not responded to the rst postcard request. In all,
75 completed parent-child questionnaires were received
(76% response rate).
Variables and Their Measurement
The variables of interest in this study were patient and
parent demographics, expectations from treatment, childs
body image, self-concept and perceptions of malocclusion,
as well as parents evaluation of their childrens level of
self-care. Some of the instruments used to measure these
variables were adapted from previous research, whereas
others are standardized psychologic scales. Still others
were developed specically for this study. Listed below are
these variables and the measures used to assess them. The
appendix includes a copy of each instrument.
On the childrens questionnaire they were asked to
record age, school, current grade, and sex, as well as
treatment status, persons involved in treatment decisions
(e.g., mother, father, other guardian, dentist, orthodontist,
and self), and perceived reasons for undergoing orthodon-
tic treatment. This questionnaire also included a rating of
how the child felt about the treatment decision, ranging
from 1 (very unhappy with the decision) to 5 (very
happy with the decision).
The parents questionnaire asked which parent was
primarily responsible for the childs orthodontic treat-
ment, which parent the child lives with on a regular basis,
and number of siblings. With regard to other family
members, parents were asked whether they or any of the
childs siblings had undergone orthodontic treatment, and
any associated problems or improvements. The parents
were asked to state the reasons for orthodontic recom-
mendations for the subject child, type of treatment ren-
dered, and reasons for rejecting treatment (if they had
rejected it). For children in orthodontic treatment and
those who had completed Phase I, parents were asked to
describe any problems the child had experienced with
their procedures or follow-up.
To assess childrens and parents expectations of or-
thodontics, good and bad, we adapted a measure of
expectancies that had been developed in an earlier
study with surgical and conventional orthodontic pa-
tients.
48
The instrument comprises a list of 15 items
representing four dimensions: (1) oral function, (2) social
interaction, (3) self-image, and (4) general health. Each
item is accompanied by a 8-point scale ranging from 3
(will be much worse after treatment) to 3 (will be
much better). The items were developed on the basis of
open-ended interviews with patients who had undergone
these procedures. They are generalizable to this younger
population of orthodontic patients. To accommodate chil-
dren who had already completed Phase I, we modied the
verbal anchors to read (3) it is much worse after
orthodontics to (3) it is better after orthodontics.
Recently this instrument was used in a study by
Phillips and colleagues
49
to determine the motivations of
patients with skeletal disharmony for seeking treatment.
The instrument was modied by these investigators to
include 24 questions with two additional dimensions, but
these items were not included in the version used in our
study. We calculated total scores for each dimension by
adding the four items representing each of the rst three
dimensions (yielding scores ranging from 12 to 12) and
the two items representing the fourth dimension. To
compare scores across the four dimensions, we multiplied
scores on the fourth dimension (general health) by two,
thereby allowing a range of 12 to 12 on all four
dimensions.
Previous studies of adults undergoing surgical ortho-
dontics have revealed that body image is generally lower
in that population than in conventional orthodontic pa-
tients but that it improves signicantly for the former
while showing only a mild increase for the latter.
50
The
measure used in these earlier studies was the Secord and
Jourard
51
Body Cathexis Scale, adapted for use in the
current investigation of younger patients. This modied
scale comprises 20 items with subscales for facial image,
facial prole image, and total body image. For each body
part, the respondent uses the original 5-point rating scale
devised by Secord and Jourard, with verbal descriptions
ranging from 1 (wish I could change it) to 5 (consider
myself very fortunate in this area).
The Harter Self-Perception Scale
52
was administered
to measure the childs perceived self-concept. This scale
comprises 36 items representing six domains: (1) scholas-
tic competence, (2) social acceptance, (3) athletic compe-
tence, (4) physical appearance, (5) behavioral conduct,
and (6) global self-worth. The items are in a structured
alternative format designed to offset the tendency to give
socially desirable responses. For each item, two opposite
types of children are described (e.g., some children nd
it hard to make friends; other children nd it easy to make
friends). The respondent must decide which type of child
is more similar to him or her and whether the description
on that chosen side is sort of true of me or really true
of me. Each item is scored from 1 to 4, where a score of
1 indicates low self-concept and 4 indicates high self-
concept. The direction of responses is reversed for half the
items to prevent response bias. Total subscale scores have
a possible range of 6 to 24. This instrument has been
validated with children in the fourth through sixth grades
and has shown good test-retest reliability and internal
consistency. Norms are available for boys and girls in the
same age range as subjects in the current study.
52
Perceived severity and type of malocclusion were
measured with the use of a series of drawings adapted
from a study by Kiyak,
53
in which various forms of
malocclusion were evaluated for their relative aesthetics.
These drawings were modied to include full-face and
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 113, No. 1
Tung and Kiyak 33
prole representations of children with anterior crowding,
anterior diastema, overbite, overjet, and open bite. Full-
face and prole drawings of children with normal occlu-
sion were placed on the left side of each page for
comparison. The drawings were intentionally made sex-
neutral, so boys and girls could rate the same images. With
the use of two visual-analogue scales, the child was rst
asked to indicate how similar his or her face was to the
left-hand drawing (i.e., normal occlusion) or the right-
hand drawing (i.e., malocclusion). Then he or she rated
the relative attractiveness of each face (normal vs. maloc-
clusion). Ratings were determined by measuring the dis-
tance (in centimeters) from the left of an X placed by
the child on each of the 12-cm lines.
To assess the parents perceptions of the childs
independence in home care and other health and hygiene
behaviors, and the childs ability to adhere to the orth-
odontists recommendations with regards to home care
and appliance wear, we adapted a brief questionnaire
from a scale constructed by Sparrow and colleagues.
54
The
original scale was implemented to assess the indepen-
dence of developmentally disabled persons. The modied
instrument consists of 21 activities that any child may
perform. The parent is asked to rate the childs indepen-
dence in performing each task, using a 5-point response
scale. A response of 1 indicates that the child needs
assistance while a score of 5 indicates that the child can
perform the activity totally independently.
Simple descriptive statistics were used to determine
the distribution and range of parents and childrens
responses to each question. Comparisons between parents
and children were made with t tests for continuous data
and
2
tests of association for categorical data. Compari-
sons among groups of children (e.g., pretreatment, post-
treatment, current-treatment groups) were made with
ANOVA and
2
tests of association.
RESULTS
Characteristics of the Sample
The sample consisted of 75 children and their
parents. Table I summarizes the major demographic
characteristics of these respondents. Children
ranged in age from 8.75 to 12.5, with a mean of
10.850.91 years. Most had recently completed
fourth grade (53%) and were from the Seattle area
(84%); the remainder live in Anchorage, Alaska.
Most children reported themselves as white (84%),
with a small number of children who identied
themselves as black (1.33%), Asian (4.0%), His-
panic (2.7%), or of mixed ethnicity (8.0%). In all
subsequent analyses these ethnic minorities were
combined and compared with white subjects. Of the
75 parent questionnaires returned, 64 (85.3%) were
completed by the mother of the child, and 71
(94.7%) parents reported that the child resides with
both the mother and the father.
According to their parents, the average age of
respondent children at the time of referral for Phase
I was 8.6 years. Most were either still in Phase I
therapy (45%) or had completed it (22%). Another
30.3% were expecting to begin Phase I in the coming
year, whereas only two (2.7%) had decided not to
undergo Phase I treatment (Table II). The primary
reasons for referral as reported by both parent and
child are presented in Table III. Childrens percep-
tions of why they needed orthodontics were consis-
Table I. Characteristics of 75 parent-child pairs
Child
Mean SD age (yr) 10.85 0.91
Grade* 53% 4th, 39% fth
Sex 52% female
Ethnicity 83.8% white
Parents
Relation to child 85.3% mother, 14.7% father
Parent underwent orthodon-
tics
62.2%
Siblings underwent orthodon-
tics
44.9%
*Remaining children were in the third and sixth grades.
Mean age at treatment 12.6 yr.
Based on 62 children with siblings.
Table II. Treatment status, based on parents reports
Age referred for orthodontics* 8.6 1.40
Age started Phase I* 9.1 1.20
Age completed Phase I* 10.2 1.74
In Phase I 45%
Phase I not yet begun 30.3%
Rejected Phase I 2.7%
*Data expressed as mean SD.
22% completed.
Table III. Primary reasons for referral
Reason
Parents
Report
(%)
Childs
Perception
(%)
Crowding 42 (56) 42 (56)
Overbite 13 (17.3) 11 (14.7)
Crossbite 7 (9.3) 1 (1.3)
General malocclusion* 3 (4.0) 7 (9.3)
Missing teeth 3 (4.0) 0 (0)
Diastema 1 (1.3) 4 (5.3)
Habits 0 (0) 1 (1.3)
DK/NR 6 (8.0) 9 (12.0)
Total 75 (100.0) 75 (100.0)
*Includes teeth dont t and problems biting/chewing.

2
Test of association 76.08, df 42, p 0.001.
American Journal of Orthodontics and Dentofacial Orthopedics
January 1998
34 Tung and Kiyak
tent with the diagnosis as reported by their parents
(
2
76.08, df 42, p .001). The primary diagnosis,
as reported by parents, was crowded teeth (56%),
followed by overbite (17.3%). The least frequently
mentioned problems were oral habits (n 0),
missing teeth and generalized malocclusion (n 3
each). Children were especially likely to describe
crossbite as poorly tting teeth or as problems with
biting into foods. It is noteworthy that nine children
and six parents did not know why the child had been
referred for orthodontics; all nine of these children
were in treatment at the time the questionnaire was
administered.
When asked to rate themselves on a visual-
analogue scale comparing normal occlusion with
one of ve types of malocclusion, children generally
perceived themselves in the normal range. Mean
scores and SDs on these self ratings (shown for one
type of malocclusion in Fig. 3) are in a relatively
narrow range. That is, despite their ability to de-
scribe verbally their particular occlusal deviation
that necessitated treatment, these children viewed
themselves in the normal range when given drawings
illustrating childrens faces with normal occlusion vs.
illustrations of malocclusion matching their own
condition.
Parents, Siblings, and Childrens Experiences
With Orthodontics
Among the children with siblings, 44.9% of these
siblings had undergone orthodontic treatment.
Among the parents themselves, 65.2% reported
Fig. 3. Childrens aesthetic rating scale. Sample malocclusion: crowding.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 113, No. 1
Tung and Kiyak 35
having undergone orthodontic treatment (mean age
at treatment 12.6 years). In general, most parents
did not recall having had problems with their ortho-
dontic treatment. Most commonly, they reported
that orthodontics had improved their self-concept
and oral function. Parents also reported that their
other children who had undergone orthodontics did
not experience major problems; however, they were
more likely to report that their other children had
had functional problems with orthodontic appli-
ances than they had personally experienced (33% of
siblings with orthodontics). The parents also de-
scribed greater improvements in these siblings oral
function and appearance than in themselves
(26.6%). Parents recollection of their own and
siblings problems were found to be related (
2

18.75, df 9, p 0.03).
Parents were also asked to describe any prob-
lems the subject child was having with orthodontics.
The largest group (42.3%) apparently had had no
problems. Another 38.5% reported some pain and
discomfort (44% when combined with those who
had completed Phase I orthodontics). Some were
having problems with retainers (15.4% of active
patients, 27% of patients who had completed treat-
ment). Compliance problems were noted by only
four parents (5.33%).
Childrens self-ratings of their satisfaction with
treatment decisions revealed generally neutral feel-
ings regarding treatment (mean 3.56, df 72, SD
1.13). However, signicant sex-related differences
emerged in satisfaction scores (t 2.11, p .05);
girls reported greater satisfaction with the decision
to undergo treatment. White children reported
greater satisfaction with the decision than did chil-
dren of ethnic-minority background (t 2.96, df 70,
p .002).
Expectations From Treatment
The 14-item measure of expectations from or-
thodontics was analyzed along the four dimensions
represented by the items. Table IV illustrates chil-
drens and parents expectations for each of the four
dimensions and the results of t tests comparing their
responses. The mean ratings by children and their
parents indicate the greatest expectation of im-
provement in self-image (e.g., appearance, self-
condence) and oral function (e.g., better chewing
and occlusion) but little or no change in the childs
social life or general health. Note that mean scores
revealed an expectation of improvement or no
change in all areas; very few children and no parents
expected orthodontics to impair their quality of life.
Although parents and childrens rank orders of
expectations in these four dimensions were identi-
cal, their mean scores differed. Parents expected
greater improvements in the childs self-image (t
4.58, p .0001), oral function (t 4.35, p .0001),
and social life (t 2.19, p .03) than did their
children. Neither children nor their parents ex-
pected much change in the childs general health as
a function of orthodontics.
Self-Concept and Body Image
Childrens ratings of their self-concept on the
Harter Self-Perception Scale
52
were summarized
Table IV. Expectations from orthodontics (N 75 pairs)
Feature Parent (Mean SD) Child (Mean SD) p
Self-image* 6.33 3.38 4.23 3.66 0.0001
Oral function 6.00 3.67 3.78 3.97 0.0001
Social life 1.55 2.36 0.93 2.29 0.03
General health 0.27 1.04 0.41 1.34 NS
*Summary scores may range from 12 (expect much decline) to 12
(expect much improvement).
Table V. Harter self-perception scores
Parameter
Norms* Sample (N 75)
Female Male Female Male
Scholastic competence 2.79 2.77 3.24 3.27
Social acceptance 2.82 2.93 2.89 3.08
Athletic competence 2.73 3.14 2.97 3.12
Physical appearance 2.74 3.14 3.09 3.35
Behavioral conduct 3.22 2.79 3.30 3.27
Global self-worth 2.90 3.02 3.45 3.44
*Based on average of fourth- and fth-graders in national sample.
Table VI. Body-image correlations (N 75 children)
Harter physical-appearance category r p
x Total body image 0.50 0.0001
x Facial body image 0.33 0.004
x Prole body image 0.43 0.0001
Table VII. Ethnic differences in aesthetic ratings
Malocclusion White (n 63) Ethnic minorities (n 12) p
Crowded teeth 1.21 2.53 0.02
Overbite 1.65 2.53 0.02
Diastema 0.99 1.67 0.01
Overjet 1.21 1.95 0.07
Open bite 1.55 1.99 NS
American Journal of Orthodontics and Dentofacial Orthopedics
January 1998
36 Tung and Kiyak
along the six dimensions specied by the scale and
compared with the normative samples of fourth- and
fth-graders tested by Harter. As shown in Table V,
our sample scored higher than or equal to the
normative samples on all six dimensions. It is note-
worthy that their global self-worth scores, repre-
senting the childs overall perceptions of self-es-
teem, was higher than any component score,
whereas for the normative sample this global self-
worth score was in the intermediate range. Self-
esteem with regard to physical appearance was
somewhat lower among girls than boys in this sam-
ple (t 1.66, df 73, p .10) but higher than that of
the normative sample.
Body-image scores were also in the intermediate
to high range for this sample. Mean scores were high
for the facial body-image items (mean 3.45, SD
0.74), for overall (mean 3.48, SD 0.71) and for
prole image (mean 3.58, SD 0.91). Compari-
sons among children who had completed treatment,
those who were in treatment, and those who were
not in treatment revealed no differences in body-
image scores. Not surprisingly, all three components
of body image were highly correlated with the
physical-appearance dimension of the Harter Self-
Perception Scale. As shown in Table VI, the higher
a childs self-rating of his or her prole, facial
features, and overall body image, the higher the
scores on the physical-appearance items of the
Harter Scale.
Ethnic Differences
Children who described their ethnicity as white
were compared with ethnic-minority children. Al-
though the latter group represented only 16% of the
total sample, they differed signicantly from the
former group in their ratings of the attractiveness of
malocclusion. As shown in Table VII, ethnic minor-
ities rated the faces more positively; differences
were signicant for crowded teeth (p 0.02), over-
bite (p 0.02), and diastema (p 0.01) and
marginally signicant for overjet (p 0.07). How-
ever, they did not rate themselves more negatively
than white children on these dimensions, nor did
they score lower on body image and self-concept.
Parents Perceptions of Childrens Self-Care
Abilities
Parents perceptions of their childrens ability to
perform various self-care activities indicated that
most believed their children were generally indepen-
dent in self-care (mean range 3.0 to 4.93). On a
scale of 1 to 5, children were reported to be most
independent in areas such as dressing themselves
(mean 4.93, SD 0.31) and fastening their seat
belts when riding in a car (mean 4.80, SD0.53).
They were considered least independent in areas
such as performing household chores (mean 3.22,
SD 0.71) and cleaning their rooms (mean 3.0,
SD 0.9). Parents rated their children as relatively
independent in the care of their teeth (e.g., brushing
and ossing) and in other areas of personal hygiene
(mean 4.2, SD 0.93 and mean 4.0, SD 0.9,
respectively).
DISCUSSION
The literature on personality development and
on the psychological aspects of physical appearance
reviewed earlier suggests that preadolescent chil-
dren are at a stage of developing a sense of self-
condence and competence. They are aware of their
own physical appearance and that of their peers.
They can accurately describe their own facial fea-
tures. Another strength of this stage of development
is that these children are more focused on the
future, less concerned about peer approval than are
adolescents. They generally are still seeking the
approval of signicant adult role models (e.g., par-
ents, health care providers); as a result they are
more likely to adhere to rules and daily routines
established by adults.
The ndings of this study support theories of
developmental psychology. Although we did not
compare preadolescents with adolescents undergo-
ing orthodontic treatment, it is apparent that chil-
dren ages 9 to 12 have many psychosocial strengths
that make them ideal candidates for Phase I treat-
ment. The children in this study were generally
aware of the type of occlusal condition for which
they had been referred for treatment. They agreed
with the diagnosis (as reported by parents) in almost
80% of cases, although 12% could not explain their
condition at all. Contrary to the work of Shaw and
colleagues,
17,18
who found that children in the
United Kingdom were most likely to be referred for
orthodontic treatment of a large overjet (7.0 mm),
the ndings of this study indicate that a low percent-
age of children were referred for treatment of this
condition. Most children and their parents reported
that crowding of teeth was the primary reason for
referral (56%), followed by overbite (17.3%). It may
be that these parents and children attributed overjet
to crowding and overbite. These ndings are more
consistent with those of Helm and colleagues
19
in
Denmark, who found that overbite was a common
reason for treatment to be sought.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 113, No. 1
Tung and Kiyak 37
Subject children scored higher on the self-con-
cept measure than did population norms for their
age, and they scored higher than previous studies of
patients seeking treatment. Furthermore, we found
no differences in self-concept scores between chil-
dren waiting for treatment, those who had com-
pleted treatment, and those in active treatment. This
nding is consistent with those of studies with
orthognathic-surgery patients reported by Kiyak and
Bell
6
and with studies of conventional orthodontic
patients reported by Albino and colleagues
31
and
Dann and colleagues.
37
On comparison of the spe-
cic domains of self-concept, scores were highest on
perceived global self-worth, behavioral conduct, and
scholastic achievement. Self-concept with regard to
physical appearance was intermediate in mean
scores, followed by the self-ratings on social accep-
tance and athletic competence. Even on these di-
mensions of self-concept, however, these children
rated themselves more positively than the normative
sample of non-orthodontic patients. In general, chil-
drens body image scores were high and were cor-
related with the childs physical appearance self-
concept. This correlation may be reective of the
patients being in treatment or anticipating treat-
ment, which promotes a tendency to see changes in
themselves even before completing Phase I ortho-
dontics.
One possible reason for the high self-concept
and body-image scores in this sample is that these
children had not yet reached adolescence, when
many enter the stage of role confusion or identity-
seeking. Their high scores may be a reection of the
increased sense of competence found at the pread-
olescent stage. Alternatively, these children may
have been gaining their self-condence by seeing the
improvements that orthodontics was making in their
appearance. It may be that they will never experi-
ence the traumas of adolescence as described by
Erikson and Freud.
43,44
Ethnic-minority children assigned more positive
ratings than did white children to drawings repre-
senting various malocclusions. This nding is con-
sistent with data from a previous study in which
ethnic differences in perceptions of various maloc-
clusions by white and Asian adults were assessed.
53
These similarities are striking when one considers
that these two samples differed widely from each
other (i.e., middle- and upper-income children seek-
ing orthodontic correction in our study, compared
with low-income adults who had never undergone
orthodontics in the earlier study). Such similarities
suggest that cultural differences inuence esthetic
values. Coupled with the ndings of studies by Soh
and Lew
24
and Wheeler et al.,
27
these studies indi-
cate a need for more research with ethnic-minority
children referred for orthodontic interventions. To
what extent does the need for treatment as deter-
mined by an orthodontist conict with that childs
value system and desire for orthodontics?
Finally, the ndings that most parents in this
sample had undergone orthodontic treatment
(65.1%) and that 48.4% with siblings had undergone
treatment suggests that this may be a segment of the
population that is more informed about the need for
and benets of orthodontic treatment than the
general population. Given their past experience with
orthodontics, these parents and their children may
not be unrealistic in expecting this procedure to
have a positive impact on their social lives and their
image of themselves. Indeed, perhaps these children
represent an ideal patient population; both their
parents and siblings have experienced orthodontics,
albeit at a later age than the child. These childrens
self-reports may have a more realistic basis than the
child who undergoes Phase I treatment with no
preparation by parents, siblings, or peers. The re-
sults of this study suggest that such children fare
very well with Phase I treatment; they appear to
adhere to home care and appointment-keeping be-
haviors and are supported in their orthodontic ex-
periences by informed parents.
The authors acknowledge the valuable suggestions
offered by several orthodontic colleagues in designing this
study and developing the questionnaires. In particular, we
thank Dr. Rebecca Poling, Dr. Anne-Marie Bollen, and
Dr. Douglas Ramsay. We also thank members of CDABO
who attended the annual meeting in Quebec City in July
1997 and gave the authors valuable feedback on the
preliminary results.
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