A hetero-rating scale was developed to assess parental behavior as a basis for studying the relation between parental behavior and child behavior during treatment. This scale is based on the modified VS. When exploring the psychometric aspects of the modified VS scale results comparable the those have been observed in the literature (8).
The VS includes a long description for each category. This description could be confusing and prevents effective and reproducible measurement. While the inter-rater reliability is outstanding, the intra rater reliability is poor to fair to good, also depending on the stage. On the contrary, despite the 3 training videos, the 20 observers did not attain the reproducibility of the experts concerning the parental hetero assessment scale indicating that some scoring expertise might be important. The parameters to be analyzed for this type of scale being numerous, one can ask the question of the applicability of this scale outside a research framework where there is enough time and where all the attention and the evaluators trained can be used, compared to a period when the practitioner is in full action: the multitude of aspects to take into account to identify a score can be too difficult. For the dental practice, one might consider scales consisting of triggers for the practitioner’s attention based on a limited number of separate aspects - signs to be considered. For research, 2 approaches options to increase reliability are possible: either in-depth calibration of each observer or scales consisting of items related to clearly defined aspects and scores (Likert scales). If a rating scale requires very extensive calibration, then its clinical applicability is questionable.
According to Ratson et al., children's behavior is greatly influenced by the attitude of parents. (12). Parents feed the child’s fears about dental care (11). Children follow their parents' reactions to better manage a new experience. They are able to perceive with precision and speed if their parents are calm or anxious, by integrating the sensory and emotional information that the latter show without even being aware of it. (23).
However, age is an important exclusion criterion to assess. Indeed, some patients were too young to have sufficient capacity to respond to MDAS. The first group of children (< 4 years) should only be eligible for children aged 3 and 4. It is from the age of 3 that children develop the ability to understand and solve problems, to memorize information and to exercise their own judgment. (24)
The data collection took place after the first peak of the health crisis following the Covid 19 pandemic. Since then and until now, wearing a mask has been compulsory in hospitals. This wearing of a mask represents an obstacle to the evaluation of behavior because parent’s facial expressions are difficult to interpret by observers (25).
Parents who understand this impact may decide to use their body and verbal language wisely to facilitate the care of their children. When the practitioner feels the inability of the parent to relax their child, certain facilitating options may be offered, such as the decision to behave as a passive observer, thus reducing the pressure on the child. A fair balance must be found between empowering the child and parental support. If support is lacking and the parent withdraws too much, this can lead to counterproductive effects (10).
The choice to involve a parent during the treatment must be a decision following the analysis of the situation and left to the free will of the practitioner (26). Children's adaptability during dental care is linked to multiple internal factors, such as age, cognitive and emotional development, and external factors such as family environment, socio-economic status and dental experience (4, 27).
The negative dental experience can be concrete and / or abstract. It can result from peer-to-peer communication with exaggerated narratives as well as frequent exposure to invasive medical care. (8). A link between the age and the intensity of stress could not be established, the study was not powered to do so. This aspect should be considered in the future, and circumstances and treatment should be included. The stress stimuli are often concentrated on dental technical procedures, which generally become more invasive with the age. It is on average around the age of 5 that first dental treatments takes place and the child is confronted with rotary instruments and a local anesthesia syringe (2).
The number of participants and observers may seem like a limit, but the randomization of the videos was chosen from a reduced number so that the observers could consciously and diligently judge the entire sample without losing focus.
This study adds an instrument to study the importance of parental influence on children's behavior and adds evidence to its presence. Knowing well the dental background of parents' anxiety could allow better management by the pediatric dentist. It would be interesting to set up the use of questionnaires prior to the first consultation, so that children and parents communicate on their behavior in the face of dental experiences. It can help the practitioner in the prediction of the attitudes of patients towards treatment (5).
This study can also be extended to other factors, for example the influence of siblings, on dental or medical interventions. To study the image and the feelings that they project towards each other when they are treated in one and the same session. Also studies on gendered parental influences are still scarce in the literature (8). Is anxiety more transmissible by the mother or the father?
The implementation of an adapted strategy with the parents makes it possible to avoid any conflict that may result from a feeling of exclusion against them. This prior adjustment leading to compliance with treatment on the part of the child. It is important to educate parents on behavior management techniques. A constructive partnership between parent and practitioner creates a solid foundation for a positive and long-lasting relationship with the child. In this way, a cycle of fear and negative apprehension will be avoided from early childhood.