DOI: 10.1111/j.1365-263X.2007.00883.
Psychosocial concomitants to dental fear and behaviour
Blackwell Publishing Ltd
management problems
ANNIKA GUSTAFSSON1, KRISTINA ARNRUP2, ANDERS G. BROBERG3, LENNART BODIN4,5 &
ULF BERGGREN6
1
Center for Orthodontics and Pedodontics, Public Dental Service, Östergötland, Sweden, 2Department of Pedodontics,
Postgraduate Dental Education Center, Public Dental Service, Örebro, Sweden, 3Department of Psychology, Göteborg
University, Göteborg, Sweden, 4Department of Statistics, Örebro University, Örebro, Sweden, 5Clinical Research Centre,
Örebro University Hospital, Örebro, Sweden, and 6Unit of Dental Behavioural Sciences, Institute of Odontology,
Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
International Journal of Paediatric Dentistry 2007; 17: 449–
459
Background. Children with dental behavioural man-
agement problems (DBMP) form a heterogeneous
group, where personal characteristics play significant
roles. Attention to everyday life and family situation
as additional background facets may help to better
understand and treat these patients.
Aim. This study describes everyday life and family
situation in child/adolescent patients referred
because of DBMP, as compared to patients in
ordinary dental care.
Design. A study group of 230 referred patients (8–
19 years old; 118 girls) was compared to a reference
group of 248 same-aged patients (142 girls) without
Introduction
Research on dental treatment problems among
children uses different constructs. Lack of
cooperation in dentistry is commonly described
as dental behavioural management problems
(DBMP) and is an evaluation of the child’s
behaviour made by the dentist/dental staff1.
Other relevant concepts, sometimes mixed
up with DBMP, are dental fear (DF) and dental
anxiety (DA). DBMP and DF/DA are not
synonymous, but they overlap. Such partial
overlap was clearly shown by Klingberg2 when
combining parental ratings of children’s DF
with DBMP notes in the dental records. In
a Swedish urban sample of children (n = 4505),
6.7% was assessed as having high DF, while
Correspondence to:
Annika Gustafsson, Center for Orthodontics and Pediatric
Dentistry, Torkelbergsgatan 11, SE-58185 Linköping,
Sweden. E-mail: annika.gustafson@lio.se
© 2007 The Authors
Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
DBMP. Patients and parents were interviewed
according to a semistructured protocol.
Results. Patients referred because of DBMP more
often lived in low socioeconomic status families,
had parents not living together, fewer leisure-time
activities, and were assessed as doing worse in social
interactions compared to the reference group. Half
of the study group had personal professional
support, and some had experienced interventions
by the social authorities. Whether these findings
apply also to children/adolescents with DBMP who
are not referred to specialist care remains to study.
Conclusions. Many children and adolescents referred
because of DBMP have a burdensome life and
family situation. This should be paid attention to
in research and in clinical care.
recordings of DBMP occurred in 10.5%. How-
ever, high DF assessments and DBMP recordings
co-occurred in less than half of the cases 2.
In Sweden, in 2003, 1.3% of all children were
referred to specialized paediatric dental clinics,
the majority (37%) because of DBMP in
combination with a substantial need of dental
treatment3.
Both DBMP and DF have been discussed in
multifactorial contexts where personal, environ-
mental, and situational factors interact 1.
Personal factors, such as general fear, tempera-
ment, and behavioural profile, may be seen as
important aspects of vulnerability. A consistent
relationship between general fearfulness and
DF has been shown4,5. Shyness, as one facet
of temperament, has been associated with DF,
and activity and impulsivity with DBMP6,7.
Negative emotionality has been related to DF
as well as DBMP6,7. Arnrup et al.7 found that
children referred because of DBMP differed from
ordinary child dental patients in temperament
449
450 A. Gustafsson et al.
and behaviour, and, which is crucial, that they
constituted a heterogeneous group, including
subgroups with diverging profiles.
Among environmental factors, it has been
well documented that parental DF (most
evidently mothers) strongly correlates to DF
in the child and seems to predispose for DF
reactions2. In addition, factors related to soci-
oeconomic status (SES) and family situation has
been suggested as risk factors for DF/DBMP,
although inconsistent findings have been
reported. In the Swedish population-based study,
Klingberg found that children from clinics in
areas with lower SES were reported with
higher DF scores than children from better-
situated areas2. In Arnrup’s clinical sample of
DBMP patients, a significant overrepresentation
of mothers scoring low on SES was reported8.
Raadal et al.9 identified social deprivation and
poverty as a risk factor for behavioural problems
in children. Furthermore, the relationship
between SES and dental disease is well
established10. It has also been shown that SES
is one of the most robust social environmental
factors influencing physical health. Early life
environments are indicated to have a long-term
influence on health and a cumulative effect,
making the impact of the social gradients
increasing with age, is also reported 11. Both
physical and psychological symptoms are
more common among socially disadvantaged
children whose health and well-being reflect
those of their parents12.
Children living with only one parent have
been reported to be overrepresented among
children referred because of DF/DBMP 8.
Hospital stays and a history of medical problems
have been associated with DA among children13
and may be seen as risk factors for DF/DBMP.
Thus, children and adolescents have different
family situations, socioeconomics, and experi-
ences of separations. In addition, they live
different everyday lives, including schools, peers,
and leisure-time activities. Lower SES has been
associated with less engagement in sports
activities among adolescents in Europe14 and
with a decline in physical activity as children
progress through adolescence15. Studies focusing
on patient’s everyday life and dental care are
rare. Skaret et al.16 showed that teenagers (12–
18 years old) who had left school had negative
Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
beliefs of dentists. Those who in addition had
high caries experience more often did not show
up at the dentist and had an increased risk
of future dropout from dental care. Among
children (4–12 years old) referred because of
DBMP, more social interaction problems have
been reported for a subgroup of externalizing-
impulsive children17. Both the externalizing-
impulsive subgroup and a subgroup of children
with an inhibited temperament had fewer peers
than extrovert-outgoing children17.
To summarize, social gradients have been
consistently related to physical health, psycho-
logical problems, and dental disease among
children. Studies focusing on social factors
and everyday life in relation to DF/DBMP are
rare. An impact on DF/DBMP among children
has been indicated, while little is known about
the adolescents. Consequently, we found it
important to explore and focus on the family
situation and everyday life of older children
and adolescents in dental care in order to better
understand and meet and treat child and teenage
patients showing DBMP.
Thus, the aim of the present study was to
describe facets of the family situation, medical
and psychosocial history, and everyday life in
a group of child and adolescent patients referred
because of DBMP, and to compare these patients
to a reference group of children and adolescents
in ordinary dental care.
Materials and methods
Subjects and procedures
The study included one study group and one
reference group of child and adolescent dental
patients and their accompanying parents. Study-
group patients were referred to the Clinic of
Specialized Paediatric Dentistry, in the counties
of Östergötland (n = 203), Örebro (n = 40),
and Jönköping (n = 10), Sweden, because of
DBMP, in combination with a need for dental
treatment. Patients referred during a maximum
time period of 3 years (2004 –2006) and meet-
ing the inclusion criteria were consecutively
asked to participate. Children with known com-
municative disorders or psychiatric diagnoses
according to the Diagnostic and Statistical Manual
of Mental Disorders (DSMIV18) were not included.
© 2007 The Authors
 Uncooperative youths: everyday life and family situation 451

In addition, patients were only included if between groups were all nonsignificant, with
the parent’s Swedish was adequate for him or total mean ages of 12.7 (SD 3.5) and 12.6 (SD
her to participate in an interview in Swedish 2.9) years in the study and reference groups,
at the beginning of the treatment period. Among respectively. Most of the responding parents
the 253 eligible patients in the study group, were mothers (85%), equal between groups
230 (118 girls; 51%) agreed to participate. The (86% and 84%, respectively).
patients were at referral 7.5 years but not Study-group patients and their parents
20 years of age. were interviewed according to a semistructured
The reference-group patients had no known interview protocol at their first visit to the
DBMP, which was controlled for in their dental specialized paediatric dentistry clinics. Follow-
records by their dentists. Reference-group ing the interview the patient and the parent
patients and their parents were consecutively separately filled in questionnaires, part of which
asked to participate when they came for is included in the present report. Reference
routine recall examination (n = 217) at four group participants were interviewed by their
public dental clinics (three in Östergötland and ordinary dental team according to a similar
one in Jönköping) or made orthodontic check- semistructured protocol, modified for use
up visits (n = 31) at three orthodontic clinics among patients in ordinary dental care. The
in the county of Östergötland. The dental questionnaires were answered, and the entire
clinics were selected to represent both urban study protocol was completed at one single
and rural areas as well as areas of different visit in conjunction with their regular recall
socioeconomic structure. The same exclusion or control scheme.
criteria as in the study group were used for All participants received information (both
selecting the reference group. A total of 248 verbal and written) about the study and that
patients (142 girls; 57%) formed the reference participation was voluntary. Approvals from
group. the Research Ethical Committee of the Linköping
Gender and age distributions of the study County Council and the Örebro County Council
and reference groups are shown in Table 1. The were obtained prior to the study.
reference group had a sparse representation
in the youngest ages, while 9- to 10-year-olds
Variables studied
counted for a larger part. There were more girls
than boys among the adolescents, in particular The semistructured interview dealt with back-
in the reference group, and reference-group ground, including socioeconomic factors and
adolescents were slightly younger than the family situation, medical and psychosocial
study group. Age and gender differences history, and the child’s daily life and psychosocial
adjustment/interaction, while parental DF was
assessed by a self-report questionnaire.
Table 1. Sample characteristics including mean ages and
distribution by age categories and gender in study and
reference groups. Socioeconomic status. As a measure of SES,
parents’ education and occupation were assessed
Study group Reference group
using the Hollingshead four-factor index of
Girls Boys Girls Boys social position19 (range 8– 66), modified for use
n (%) n (%) n (%) n (%) in Sweden by Broberg (Swedish adaptation of
the Hollingshead four-factor index of social
Children
7–8 years 14 (12) 23 (21) 9 (6) 1 (1) position. Unpublished paper from the Depart-
9–10 years 35 (30) 18 (16) 41 (29) 42 (40) ment of Psychology, Göteborg University,
11–12 years 19 (16) 28 (25) 28 (20) 33 (31) Göteborg, Sweden, 1992). In the logistic regres-
Adolescents
13–14 years 14 (12) 10 (9) 19 (13) 12 (11)
sion analyses, the score was dichotomized to
15–16 years 20 (17) 11 (10) 31 (22) 11 (10) indicate low SES (scores < 30) or not. Low SES
17–19 years 22 (19) 22 (20) 14 (10) 7 (7) was represented by occupations as, for example,
All subjects 118 112 142 106
shop assistant, assistant nurse, truck driver, or
Mean age (SD) 12.7 (3.4) 12.8 (3.6) 12.9 (3.0) 12.2 (2.6)
having disablement pension.

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Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
452 A. Gustafsson et al.
Family situation. Questions were asked about
whether parents were divorced/separated, if
the child lived with one or both of the parents,
or with other relatives or foster parents. We
also asked about experiences of separation
from both parents; separations caused by inter-
ventions from social authorities were registered
separately.
Parental DF was assessed using Corah’s Dental
Anxiety Scale (DAS)20. The DAS measures
reactions to four imagined dental treatment
situations, including appointment tomorrow
and three different treatment situations. For
each situation, responses are scored from calm
(1) to terrified (5), giving total scores from
4 to 20. Average DAS scores of 8–9 in ordinary
patients and 13 or above among fearful dental
patients have been reported in several studies20,21.
Medical and psychosocial history. Medical history
included information about diseases, accidents,
visits to doctor or school nurse, and hospital-
ization periods. The present report includes
data on experienced hospitalization and reasons
for that. Children/adolescents and their parents
were asked whether the child/adolescent had
or previously had support from a school
psychologist, social worker, or other psychosocial
professional (yes/no). If yes, the respondent
was asked to indicate the main reason for that
contact.
The child’s or adolescent’s psychosocial adjust-
ment was evaluated using parental ratings of
the child’s (i) interaction with brothers/sisters;
(ii) interaction with other children; (iii) conduct
towards the parents; (iv) playing and working
by him- or herself; and (v) his or her school/
preschool performance. For each item, the
parent rated their child as doing worse (0),
equal to (1) or better (2) than children in general
of the same age. As a global measure of social
interaction problems (yes/no), we used a dicho-
tomy over individual mean ratings from the
five items (i–v). Mean ratings below 1 indic-
ated social interaction problems (yes), while
mean ratings equal to or exceeding 1 indicated
no social interaction problems.
Everyday life. As part of the interview, specific
questions were asked about friends (how
many close friends) and leisure-time activities
Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
(number of sport activities, music activities or
other activities).
Statistical analyses
The results are presented using descriptive
statistics (proportions, means, standard deviation)
and graphic presentation. Univariate group
differences were tested with Student’s t-test
for parametric data and chi-squared test for
proportions. For group comparisons of non-
parametric ordered data we used chi-squared
test for trend. Multivariate comparisons of the
study and reference groups were performed
using logistic regression analyses with group
as outcome variable and selected measures
(see result section) as potentially discriminatory
variables. The level of significance was set at
5% (i.e. P < 0.05). The statistical analyses were
performed using SPSS version 15.0 or StatXact 7.
Results
Family situation
The family’s SES, as indexed by both parents’
educational level and occupation scores, differed
between groups, with the parents of the study
group showing a significantly lower SES level
as compared to the parents of the reference
group. In addition, when dichotomized into
SES categories, low SES was significantly more
frequent in the study group compared to the
reference group (66% vs. 28%; P < 0.001;
Table 2).
A significantly higher proportion in the study
group as compared to the reference group had
parents who did not live together (51% vs.
26%; P < 0.001; Table 2). This difference was
more pronounced among the adolescent
subgroups (59% vs. 28%; P < 0.001). Within
the study group, 23 individuals (10%; 4 girls
and 4 boys among the children, 6 girls and 9
boys among the adolescents) had, as a result
of interventions by social authority, experi-
enced separation from both parents and had
been living with relatives or foster parents as
compared to none among the reference-group
children or adolescents. Furthermore, parental
DF was significantly higher in the study group
as compared to the reference group (Table 2).
© 2007 The Authors
 Uncooperative youths: everyday life and family situation 453

Table 2. Family and child situation by group (study vs. reference). Differences between study and reference groups are
tested with chi-squared test and Student’s t-test, respectively.

Study vs.
Study group Reference group reference group

n* Count (yes) % (yes) n* Count (yes) % (yes) χ2 P-value

Low socioeconomic status 201 132 66 218 62 28 58.30 < 0.001

Not living with both parents 226 115 51 241 63 26 30.27 < 0.001
Taken care of by social authority 230 23 10 248 0 0 26.05 < 0.001
Experience of hospitalization 230 92 40 244 97 40 0.003 0.96
Personal professional support 229 125 55 243 37 15 81.02 < 0.001
Social interaction problems 205 61 30 217 20 9 28.67 < 0.001
No leisure-time activities 230 117 51 243 44 18 56.49 < 0.001
No close friends 230 14 6 243 9 4 1.45 0.23
Mean SD Mean SD t P-value
Socioeconomic status (SES score) 203 29.4 10.9 226 38.2 11.7 –8.05 < 0.001
Parental dental fear (DAS score) 223 10.7 5.1 239 7.5 3.8 7.67 < 0.001

*n varies between different variables according to missing data on single items.

Table 3. Parental ratings of the child’s psychosocial adjustment (as doing; worse, equal to or better than same-aged children
in general). Distributions are given as counts and differences between study and reference groups are analysed with
chi-squared tests for trend.

Study vs.
Study group Reference group reference group

n* Worse Equal to Better n Worse Equal to Better χ2 P-value

Interactions with brothers/sisters 215 19 166 30 225 10 167 48 6.59 0.01

Interaction with other children 227 18 171 38 239 8 163 68 12.15 < 0.001
Conduct towards the parents 228 22 169 37 238 7 167 64 13.74 < 0.001
Playing/working by him-/herself 227 27 144 56 237 15 136 86 9.76 0.002
His/her school performance 219 52 126 41 234 10 123 101 51.93 < 0.001

*n varies between different variables according to missing data on single items.

Medical and psychosocial history
The proportions of individuals with experiences
of hospital stays were equal between groups
(Table 2). The reasons for hospitalization varied
with trauma/injuries (14%), followed by
reversible organic diseases (12%) being the
most frequent reasons within the study group,
while the reverse (reversible organic diseases,
17%; trauma/injuries, 8%) was true for the
reference group, but group differences were
nonsignificant.
The proportion of children having support
from school psychologist, social worker, or other
psychosocial professionals were almost four
times higher in the study group as compared
to the reference group (55% vs. 15%; P < 0.001;
Table 2). This support was most commonly
related to school problems (17% vs. 1%),
personal psychosocial problems (depression,
anxiety, suicide attempt; 8% vs. 4%), and
behavioural problems including neuropsychi-
atric disorders (7% vs. 2%). Violence/abuse in
the family was only reported in the study
group (6%). Distributional differences between
groups according to the categories of reasons
reported were not tested for statistical sig-
nificance since the reference group was
represented only by single or few cases in most
categories.
Psychosocial adjustment was evaluated using
parental ratings of the child’s or adolescent’s
ability to handle social interaction and per-
formance situations (Table 3). While most
parents in both groups tended to rate their
child’s ability equal to other children, more

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454 A. Gustafsson et al.
Fig. 1. Parents report of number of leisure-time activities
among the study and reference groups. Frequency is given
as percentage within each group. The distribution in
different categories of activity differed significantly between
groups (χ2 = 61.94; P < 0.001).
Fig. 2. Parents report of number of close friends among
the study and reference groups. Frequency is given as
percentage within each group. The distribution in different
categories of number of close friends differed significantly
between groups (χ2 = 12.38; P < 0.001).
study group parents indicated that their children
did worse than other children in these situations
(chi-squared test for trend; Table 3). This was
most evident regarding school performance.
After dichotomization into social interaction
problems or not (see method section), the
proportion of children and adolescents with
such problems was three times higher in the
study group as compared to the reference
group (30% vs. 9%; P < 0.001; Table 2).
Everyday life
Number of leisure-time activities and number
of close friends are shown by group in Figs 1
and 2. The distribution in frequency categories
Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
of leisure-time activities differed significantly
between the two groups, with the study group
being significantly less engaged in organized
activities as compared to the reference group
(chi-squared test for trend; χ2 = 61.94; P < 0.001;
Fig. 1). Half of the study group reported, at the
time of the study, no regular activity, while
this was reported by less than 20% of the
reference group (Fig. 1; Table 2). The difference
between study and reference group was also
obvious when analysed separately for age and
gender subgroups, and it is worth to notice
that the most evident difference was revealed
between the groups of adolescent boys, out of
whom 77% in the study group as compared
to 28% in the reference group reported no
leisure-time activity (P < 0.001). In general,
the patterns of differences between study and
reference groups were the same also when
separated by gender and age group. However,
although not tested for significance, larger
contrasts were revealed between subgroups
of boys as compared to girls and between sub-
groups of adolescents as compared to children.
The number of close friends differed between
groups, indicating that subjects of the study
group had fewer friends as compared to the
reference group (chi-squared test for trend;
χ2 = 12.38; P < 0.001; Fig. 2). A few individuals
(equal between groups) were reported to have
no close friends at all (Table 2).
Multivariate analysis
Variables of family situation (low SES, not living
with both parents, parental DF) and psychosocial
adjustment (personal professional support,
social interaction problems) were entered
into a sequence of multiple logistic regression
analyses with study (1) versus reference (0)
group as the dependent variable. In a first step,
independent variables were tested one by one
without and with the inclusion of age (two
levels) and gender groups. With this inclusion,
the odds ratio (OR) for ‘personal professional
support’ increased from 6.7 (95% CI 4.3–10.3)
to 7.6 (95% CI 4.8–12.2), while other variables
were unaffected. In a second step, the variables
under investigation were included simultane-
ously in the model, without and with the
addition of age and gender groups (data not
© 2007 The Authors
 Uncooperative youths: everyday life and family situation 455

Table 4. Multiple logistic regression models (in total and separately by age and gender subgroups) for assignment to study
group (final steps).

Model Variable OR 95% CI P-value

Main model (all) SES low (yes/no) 3.4 2.1–5.6 < 0.001
Not living with both parents (yes/no) 2.1 1.2–3.5 0.01
Personal professional support (yes/no) 3.7 2.1– 6.5 < 0.001
Parental dental fear (DAS) 1.1 1.1–1.2 < 0.001
Subgroup models
Children
Girls* SES low (yes/no) 3.1 1.4 – 6.8 0.01
Parental dental fear (DAS) 1.1 1.0 –1.2 < 0.001
Boys† SES low (yes/no) 7.0 2.6 –18.7 < 0.001
Not living with both parents (yes/no) 4.3 1.5 –12.3 < 0.001
Personal professional support (yes/no) 7.1 2.3 –21.7 0.001
Adolescents
Girls‡ SES low (yes/no) 4.3 1.4–12.7 < 0.001
Personal professional support (yes/no) 7.2 2.4–21.9 < 0.001
Boys§ SES low (yes/no) 5.7 1.4–22.4 0.01
Personal professional support (yes/no) 6.3 1.6 –24.6 0.01

The models are based on complete data for 359 subjects (174 study group vs. 185 reference group). Models for subgroups are based
on data as follows: *116 child girls (53 vs. 63), †114 child boys (59 vs. 55), ‡77 adolescent girls (33 vs. 44), §52 adolescent boys (29
vs. 23). Variables included in the analyses were SES low, not living with both parents, personal professional support, social interaction
problems (yes/no), parental dental fear. Variables not reported in the table did not enter the model.

shown). In a final analysis of the total groups,
a stepwise conditional inclusion of the variables
under investigation was performed (Table 4).
Forced inclusion of age and gender again
revealed an increase in OR for ‘personal
professional support’ (from 3.7 to 4.1), while
other variables were unaffected. The model
was supplemented by separate analyses for age
and gender subgroups with forward stepwise
inclusion of the same variables, and results
showing somewhat different models are reported
in Table 4.
The main model (‘all’, Table 4) confirmed
group differences in SES, parents’ cohabitation,
children’s or adolescents’ personal professional
support, and parental DF. Personal professional
support was the variable showing the highest
OR for allocation to the study group, but failed
to discriminate between study and reference
group for child girls (subgroup model 1; Table 4).
Only low SES and parental DF remained in
the model for child girls. In the other three
subgroups, the increased ORs (6.3–7.2) for
personal professional support point to its
clear and significant contribution. Low SES
(OR = 3.4 in the main model (‘all’ Table 4) was
the only variable with discriminating ability
in all subgroups. The varying ORs indicate a
stronger contribution among boys. Not living
with both parents entered the model only
for child boys (Table 4). Thus, models for
adolescent girls and boys were similar, pointing
to the impact of SES and personal professional
support, while models for the younger children
partly diverged by including parental DF for
girls versus not living with both parents for
boys.
Discussion
The present study was designed to give a picture
of the everyday life and family situation of a
group of child and adolescent dental patients,
referred because of DBMP and a need of dental
treatment, the combination being the most
common reason for referral to specialized
paediatric dentistry in Sweden3. These results
were compared to a reference group of children
and adolescents in ordinary dental care. The
occurrence of single-parent families, child–
parent separations, and professional support
actions were clearly more frequent among
study-group patients referred because of DBMP
than among reference-group patients in
ordinary dental care. Study-group patients more
often lived in low SES families and had fewer
close friends and leisure-time activities. They
were also assessed as performing poorer at

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Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
456 A. Gustafsson et al.
school and to have social interaction problems
more often. Regression analyses revealed that
belonging to the study group was most clearly
predicted by low SES and having had personal
professional support. Taken together, these
findings indicated that a significant proportion
of children and adolescents referred because of
DBMP live a burdensome everyday life, which
should be paid attention to in dental care when
meeting and treating these patients.
Although an increasing rate of single-parent
families has been reported in Western societies,
our findings for the study group clearly
exceeded what could be expected, while
reference group data paralleled norm data22.
Generally, children live with one or both
of their parents, but for a minor proportion
(< 1/1000 in Sweden), interventions by the
social authority result in separation from
both parents23. Among children in the study
group, 10% had been investigated by the social
authority and separated from the parents
during different periods of their lives. This was
a surprisingly high proportion compared to the
reference group, where no such interventions
were reported.
The higher ratings of parents’ own DF in the
present study group equalized and confirmed
previous findings2,8,24.
It has been reported that deprived social
circumstances are linked to disease by psycho-
social and behavioural pathways. Even a quite,
subtle kind of social disturbances such as
loneliness can lead directly to poor health
behaviour25. In our investigation, the study-
group patients had significantly fewer close
friends, fewer organized activities, and a nearly
four times higher frequency of personal
professional support as compared to the
reference-group patients. Reference-group data
corresponded well with the general Swedish
population, where 10–15% consulted pro-
fessional support during childhood and/or
adolescence23. Although the reasons for support
were not tested for statistical significance bet-
ween groups, the reports from the study group
gives a picture of a broad range of problematic
everyday situations and psychological pro-
blems requiring professional support. School
problems, which were reported to be the most
common reason for support, may indicate a
Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
background of social interaction problems and
difficulties to adjust to rules and demanding
situations. A similar tendency was identified
by Arnrup et al.17, who observed that a subgroup
of externalizing-impulsive children with DBMP
had a temperament and behavioural profile
similar to that of children diagnosed with
oppositional defiant disorder or conduct dis-
order. Other common reasons for support were
personal psychosocial problems in terms of
depression, anxiety, and suicide attempts,
which points to a more internalizing or inhibited
way of functioning.
Everyday life has, to our knowledge, not
previously been investigated in paediatric
dentistry. However, in other research areas, it
has been shown that children or adolescents
who are participating in organized activities
and are active in their spare time perceive
their health as better and they are also reported
having more friends 12. Half of the study-group
patients did not participate in any organized
activity at all as compared to a minor proportion
of the reference group, whose figures parallel
those of the general Swedish population23. This
difference was particularly evident when com-
paring the adolescent subgroups, where only
25% of the study-group adolescents participated
in at least one activity as compared to 75% of
the adolescents in the reference group.
The picture of a burdensome everyday life
situation drawn for study-group patients was
clearer in the adolescent subgroups. This may,
in line with findings within paediatric research11,
reflect that problems accumulate over time, but
may also be due to different reasons for
referral at different ages. Both assumptions
seem empirically valid, since clinical experience
from specialized paediatric dental care indicate
more generalized problems among adolescents
referred because of DBMP. For young children,
many fear reactions and uncooperative be-
haviour can be explained by developmental
aspects26 and, thus, by 4–6 years of age many
preschoolers with DBMP will be perfectly
able to cope with the demands of the dental
situation. Thus, a reflection of heterogeneity
should be assumed, also in these social, family
and everyday life factors, when evaluating
DF/DBMP problems among children and
adolescents.
© 2007 The Authors
 Uncooperative youths: everyday life and family situation
In addition, the fact that our study group,
similar to other clinical DBMP samples, pre-
sented with an urgent or extensive treatment
need (data not shown), commonly due to
accumulated and untreated caries disease, calls
for attention. Thus, interactions have to be
expected between social factors, dental disease,
and DF/DBMP. Despite the decline in the overall
prevalence and incidence of dental caries in
Western societies, areas with persistent high
caries are often characterized by low SES27,28.
It is important to remember that neither
socioeconomic factors in particular nor social
addresses29 in general, by themselves can account
for psychosocial outcomes. This is shown
by the fact that most children from poor
single-parent families will not be referred to
paediatric dentistry (because of DBMP or for
any other reason). It takes a risk model to
understand how social addresses translate into
psychological or dental outcomes. Such a model
must include the links from one level of
explanation (e.g. low SES) to another (e.g.
DBMP or high incidence of caries). For caries
the most important link might be bad eating
habits and/or bad oral hygiene. For DBMP one
of the links can be lack of parental support
leading to fewer visits to the dentist for regular
check-ups without the need for invasive
treatment, and thereby less positive, or at least
neutral, experiences of going to the dentist.
Another possible link, especially when troubles
have started to pile up, is low internal locus
of parental control30, and thus lack of ability
to help the child develop adequate coping
mechanisms in difficult situations. This in
turn will most probably lead to avoidance as
becoming the most dominant way to handle
difficulties, as for example when going to the
dentist when one is afraid and does not want
to go. This is in agreement with the findings
of Skaret et al.16 where an increased risk of missed
or cancelled appointments were reported for
adolescents with high caries experience,
negative beliefs of the dentists, experiences of
pain during dental treatment, and for those
not attending school. The important take-
home message for the dentist is not to view
some children’s family background as a cause
to children’s difficulties but as a possible risk
factor. Only families actually showing the
© 2007 The Authors
Journal compilation © 2007 BSPD, IAPD and Blackwell Publishing Ltd
457
expected links are ‘risk families’. Furthermore,
research in developmental psychopathology
has convincingly shown that risk factors are
related to negative outcomes not in a linear,
but in an exponential way31,32. Thus, it is the
number of risk factors, rather than one in
particular, that the dentist should be observant to.
The public dental clinics, from which the
reference group was recruited, were selected to
represent both urban and rural districts as well
as areas of different socioeconomic structure.
However, selection bias may have occurred. At
least one study indicate that a higher propor-
tion of families from rural districts avoid dental
care, and that a higher proportion of families
from low SES areas have a negative attitude
towards dental care16. Based on this study, it
is reasonable to assume a higher dropout rate
among socially disadvantaged families.
Furthermore, some of the interview questions
may have come close to personal integrity, and
reliability differences due to the somewhat dif-
ferent settings for study and reference groups
cannot be excluded. For example, violence/
abuse at home (not reported at all among the
reference group), may be a highly protected
secret and probably difficult to get reported
with validity in parental assessments.
In addition, it was presumed that the child
and adolescent patients in the study group were
referred because of DBMP to the specialized
paediatric dentistry clinics, but in fact, DBMP
as reason for referral is usually combined with
a significant need for dental treatment. Unfor-
tunately, data regarding the caries situation of
the subjects in the reference group is lacking.
Thus, the present investigation does not allow
any evaluation of the interactions between
DBMP, low SES, and dental disease.
In conclusion, this study revealed that a sig-
nificantly higher proportion of children and, in
particular, adolescents referred for specialized
care because of DF and/or DBMP live a burden-
some life with respect to family situation and
everyday life, when compared with same-aged
patients in ordinary dental care. A number of
factors add to a picture of a negative develop-
mental pattern, where having fewer friends,
participating in fewer activities, and needing
more professional support may subsequently
cause concomitant negative feelings, thus
458 A. Gustafsson et al.
possibly creating a vicious cycle of social inter-
action problems and increasing difficulties in
everyday situations with possible consequences
also in dental care.
When formulating our aims, a more difficult
life situation, as described by facets of the
family situation, medical and psychosocial
history and everyday life, was hypothesized
for the group of children and adolescents
referred because of DBMP. It stands clear that
several factors interact in the development
and maintenance of DBMP. This study adds
knowledge about the related aspects of family
situation and everyday life, but it remains to
study whether the documented associations
between low SES and other family risk factors
on the one hand, and DBMP on the other, is
limited to children who get referred, or if
it holds also for children with DBMP who
remain in regular dental care.
What this paper adds
• This paper adds knowledge about aspects of family
situation and everyday life that are related to the
development of DBMP among children and adolescents
referred to specialized paediatric dentistry.
• It also supports the view of DF/DBMP as outcomes of
multifactorial aetiological contexts, where vulnerability
and risk factors combine and interact differently for
different subgroups of children and adolescents.
Why this paper is important to paediatric dentists
• Knowing more about the everyday life situation of
especially older children and adolescents with DBMP
can serve as basis to understand their sulkiness better.
This can make it easier to meet, and treat them with
empathy rather than with irritation, which in turn will
keep more of them in treatment.
Acknowledgements
This study was supported by the Swedish
Dental Society, Arvid Syrrist’s foundation,
Göteborg University, and Östergötland County
Council.
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