Temperament and trait anxiety as predictors of child behavior prior to general anesthesia for dental surgery Rocio Quinonez, BA, BScDent, DMD Robert C. Santos BA, MA Ron Boyar, DMD, MSc Howard Cross, DMD, MSc Abstract dren for whom the presurgical experience may be po- Children‘s individual styles of interaction with the en- tentially damaging (and may therefore benefit from vironment (temperament) influence stable tendencies to- presurgical sedation) and to aid in the development of wards distress (trait anxiety) and context-specific mani- techniques to prevent and ameliorate anxiety. festations of distress (stateanxiety). Measures of tempera- Anxiety and temperament ment and trait anxiety were examined as predictors of state Traditionally, theories of anxiety reflected the en- anxiety (i.e., disruptive behaviors) in the presurgical set- during debate between nature (genetic influences) and ting. During a 2-month period, 51 nonpremedicated, nurture (environmental influences).6, Anxiety was healthy children (M = 3 years of age) were consecutively viewed as either a trait (a genetically based variable that studied as they presented to a hospital setting for dental is stable across different environments) or a state (a treatment under general anesthesia (GA).Using correla- context-dependent that is variable in different environ- tion and backward multiple regression analyses, one tem- ments). A more useful view recognizes anxiety as the perament category (shyness), but not trait anxiety (the product of a complex interplay of both genetic and en- rmised CMAS),predicted disruptive behaviors (the revised vironment influences over the life span. At the center MBPRS) during preseparation (r2= .16, P = .0038) and of this interactional, developmental view is the concept separation (9= .09, P = .0281)from parents. Shyness, age, of temperament. and gender best predicted disruptive behaviors during Temperament refers to infants’ and childrens’ indi- preseparation (multipleR2 = .32, P =.0005). Temperament vidual styles of interaction with the environment. Tem- (a) predicts children’s distress in the presurgical setting, perament appears heritable and stable across time, but and (b)appears to be moderated by age, gender, and inter- modifiable by later environmental influences8 Early personal factors. Awareness of temperamental influences temperamental vulnerabilities appear to be precursors can help predict children’s behavior and aid in the of trait anxiety: and influence negative behaviors elic- presurgical care of children.(PediatrDent 19:427-31,1997) ited by different contexts, or state anxiety.1° Finally, early temperament predicts the appearance of multiple, egative behaviors are often displayed by chil- specific phobias several years later.” dren undergoing GA without premedication To date, few dental-related studies have examined N (i.e., without pharmacological intervention).’ the role of temperament as a predictor of negative be- These behaviors are often suggestive of anxietry and havior. Lochary et aI.,’* using the Toddler Tempera- distress. If unattended, such anxiety may lead to life- ment Scale (TTS), found that approachability predicted long fears, and ultimately result in avoidance of future struggling behavior in children who required conscious treatment and interference with care delivery.’-‘ sedation. Radis et al.,13 using the Behavior Style Ques- The use of conscious sedation has improved the tionnaire (BSQ), found similar results for initial dental quality of care of children undergoing all dental pro- examination: approachability and adaptability pre- cedures, including those undergoing GA. However, dicted quiet behaviors in 3 year olds, whereas intensity because of inadequate training and associated risks, and activity predicted crying behavior in 5 year olds. many practitioners are reluctant to premedicate. Risks The rating scales (TTS, BSQ) used in these studies were include progressive loss of consciousness, airway pa- based on the early nine-factor temperament model of tency and ventilatory response, and other unpredict- Thomas and Chess.I4Later analyses and evidence have able systemic sequellae.1,5With or without premedica- shown that the nine-factor model has no emperical ba- tion, it is important for practitioners to understand the sis,15 and the three-factor EAS model is a better predic- antecedents of anxiety for two reasons: to identify chil- tor of later personality and behavior.15The three fac- Pediatric Dentistry - 19:6,1997 American Academy of Pediatric Dentistry 427 from 2 to 5 years in age, were seen during a 2- month period as they presented for treatment at Children’s Hospital in Winnipeg, Manitoba, EAS Subscale Definition (features of high scorers) Canada. Chldren were assigned to day-surgery for - - vz dental treatment under GA by their respective pe- Emotionality Distress-proneness (e.g., crying, tantrums) diatric dentists. Selection for operating room treat- Activity Behavioral arousal (e.g., high rates of ment was based on three criteria: 1)children with speaking and moving) behavioral problems or extreme uncooperative Sociability Preference for being with others versus behavior; 2) children too young to cooperate in the being alone (e.g., sharing, attention-seeking) dental chair; and 3) children with extended dental Shyness Derivative of Sociability: A tendency to be tense and inhibited with strangers or causal treatment required. Criteria 2 and 3 were also acauaintances guided by geographic and language consider- ations. For example, it is more cost effective to pro- vide operating ioom treatment to children who have travelled from distant communities rather than re- tors are emotionality, activity, and sociability. A fourth quiring repeated visits over long periods of time, as component, shyness, is considered a derivative of so- well as to children with whom practitioners are unable ciability (Table l).The EAS Temperament Survey for to communicate, due to language barriers. Children: Parent Rating (EAS), a 20-item instrument Prior to treatment, patients’ medical histories were wherein parents rate their children on a five-point scale screened by the attending nurse. Parents and guardians (1 = not characteristic, 5 = very characteristic), provides read an overview of the study and provided written in- a measure of the EAS factors. Scores for emotionality, formed consent as outlined by Human Ethics Commit- activity, sociability, and shyness are each indexed by tee standards. five items. The scale shows good test-retest reliability (M = .70) and internal consistency (M = 33) for children Assessment protocol and procedures 1 to 9 years of age, and there is considerable evidence All patients were assessed in three phases. In the for the heritability and stability of the EAS factor struc- first phase, after the nurses’ screening and prior to ture.15To our knowledge, our present study is the first moving the patient to the operating room area, we ad- to use the EAS model in a dental-related setting. ministered a structured interview to each patient’s par- The ”goodness of fit” concept describes the relation- ent or guardian. This interview included three mea- ship between a child’s temperament and a specific set- sures: l)a questionnaire soliciting basic demographic ting.I4 This concept implies that certain temperament data (age, gender, ethnicity); 2) the EAS, providing a profiles are more harmonious with the dental situation temperamental profile for each child;I5 and 3) the than other profiles. Poor goodness of fit results in a child CMAS,’6 measuring the child’s level of trait anxiety. We who becomes easily upset, displays irregular biological deleted 19 age-inappropriate items from the CMAS, functioning, shows intense and often negative reactions resulting in the 28-item revised version (CMAS-R) used to environmental changes, and tests the patience of both in the interview protocol. Higher CMAS-R scores in- parents and practitioners. dicate higher levels of trait anxiety on a four-point scale Lochary et al.’* suggested that GA may be a more ef- (1 = not at all, 2 =just a little, 3 = pretty much, 4 = very fective, compassionate option for children showing poor much).’” Because very young children may be unable goodness of fit between temperament and dental setting to report their internal experiences, we used the (e.g., behavioral problems). Routinely, practitioners con- parent’s version of the CMAS. Although parents of the sider hospitalization with GA administration for two same child show high interrater reliability regarding groups: children with behavioral problems and children their child’s anxiety, parents and their children clearly too young for dental chair treatment. Consequently, provide different assessment perspectives on anxiety.I7 pediatric clinicians must consider the potentially nega- Nevertheless, parents remain an important source of in- tive impact of the hospital and GA experience, both be- formation on anxiety in their children.l8 fore and after surgery, arising from poor goodness of fit. In the second phase, we rated each child along the The purpose of the present study was to investigate way to the operating room, using MBPRS.I9The MBPRS whether the temperament and trait anxiety of is an observer-based measure of state anxiety-disrup- nonpremedicated children could predict their levels of tive behaviors in a given setting. Prior to the study, we disruptive behaviors in the presurgical setting-their revised the original scale to fit the hospital operating- state