Investigation of Adjustment Problems in Children Receiving Orthodontic Treatment and the Resilience Factor

Background: In this study, various psychological characteristics affecting psychological maladjustment in children receiving orthodontic treatment were examined. Aim: In this context, the predictive and mediating relationships between emotional reactivity, intolerance of uncertainty, psychological resilience and psychological maladjustment were discussed. Design: The study was conducted with 543 children and adolescents getting orthodontic treatment. Systematic and convenient sampling methods were followed in the selection of the sample. Standardized measurement tools (The Emotional Reactivity Scale, Intolerance of Uncertainty Scale, Brief Resilience Scale, Depression Anxiety Stress Scale) and online data collection processes were used in the data collection process. Results and Conclusions: Findings have shown that emotional reactivity and intolerance of uncertainty pose a risk for psychological maladjustment in children and adolescents receiving orthodontic treatment, but psychological resilience has a protective function against this risk. It is considered that these ndings may contribute to the expansion of pediatric dentists' perspectives on the secondary outcomes of orthodontic treatment practices.


Introduction
Orthodontic treatment is a relatively long and laborious treatment process that is used in the treatment of common dental ailments today, and the individuals who apply for this treatment are mostly children and adolescents. The treatment process is usually spread over a long period of 1-2 years. Therefore, it seems possible that some secondary psychological consequences may occur depending on the treatment process. In this direction, it is thought that the uncertainty of the treatment process, the fear that occurs due to orthodontic treatment and the re ections of the apparatus used on the appearance may trigger the aforementioned secondary psychological results.
Individuals' reactions to di cult living conditions are generally de ned as shock, panic, acute stress, posttraumatic stress disorder, anxiety disorder and depression, etc. 1,2 and these symptoms indicate the individual's psychological adjustment skills. Considering psychological adjustment as the ability of the individual to cope with daily life di culties, to control intense anxiety, depressive symptoms and stress factors, it can be said that di cult living conditions have an effect that challenge the psychological adjustment skills of the individual. It can be said that the long and troublesome orthodontic treatment can put pressure on these symptoms and can challenge the individual's adjustment skills. It can also be said that the traumatic fear experienced by children and adolescents due to the COVID-19 process in the last year 3,4 will also intensify the risk factors that develop due to orthodontic treatment and put these individuals in a disadvantaged position.
It is possible that orthodontic treatment causes fear depending on the age of the child. It has been suggested by Ornell et al. 5 and Shigemura et al. 6 that if fear, which is a defense mechanism that the individual shows in the face of dangerous situations, is disproportionate to the conditions of the individual, it may pave the way for various psychological disorders such as anxiety, depression, stress and OCD, etc. 7,8 Therefore, it can be thought that the fear that may arise during the orthodontic treatment process can have various risks in terms of psychological adjustment. As a natural result of the COVID-19 pandemic, it is thought that the negativities experienced in treatment planning due to quarantine and social distancing practices increase the risk in children and adolescents and may intensify their disadvantaged position. 3 In this context, research results 4,9 are thought to support this view, showing that the fear of catching COVID-19 causes intense emotional and behavioral consequences such as boredom, loneliness, anxiety, sleep problems and anger. Thus, it can be thought that the psychological symptoms that develop in relation to the treatment in individuals receiving orthodontic treatment may worsen with the effect of the risk factor created by COVID-19 pandemic.
It is also thought that some psychological qualities of children may increase secondary results due to orthodontic treatment. Among these qualities, the intensity of the emotions experienced by the individual in various situations and emotional reactivity, which de nes the reactions elicited depending on this intensity, can be shown. 10,3 It is considered that high emotional reactivity may pave the way for the development of psychological symptoms related to the treatment process in children. Literature data show that high emotional reactivity is associated with major depression 11 , anxiety disorders 12,3 and OCD symptoms 13 . No studies addressing the role of emotional reactivity in orthodontic and dental treatments have been found in the literature. Therefore, addressing the role of this variable is important in understanding possible risk factors in orthodontic treatment planning.
Another risk factor for the secondary results of orthodontic treatments is intolerance of uncertainty. İntolerance of uncertainty is de ned as a tendency to react emotionally, cognitively and behaviorally to uncertain situations and events 14 . It has been reported that people with high intolerance of uncertainty tend to see uncertainty situations as annoying and stressful, to avoid this uncertainty, and to experience di culties in their functioning in situations involving uncertainty 15,16 . It has also been argued that their perceptions and interpretations of uncertain situations contain a negative bias and therefore these people are more prone to interpret uncertain situations as threatening 16 . In this context, it is thought that since orthodontic treatments require a long-term process and the uncertainty about the duration and success of the treatment, it is an important risk factor in terms of psychological symptoms.
Despite these negativities, in orthodontic treatment, besides the negative characteristics of individuals, there are individual qualities such as psychological resilience which has a protective function 2 . Psychological resilience is de ned as the ability of an individual to recover quickly in the face of di cult living conditions, recover and quickly return to his former state after being injured 9,17 . Similarly, it is de ned as the ability of the individual to be successful in the face of uncertain and challenging processes 18 and to quickly return to the position to ful ll the duties and behaviors expected of him 19 .
From this point of view, it can be said that psychological resilience is an important protective feature to consider in reducing the risk and psychological symptoms caused by emotional reactivity and intolerance of uncertainty in orthodontic treatment.

The Current Study
This study sets out to examine various psychological variables that predict psychological maladjustment and mediate these predictive relationships in children receiving orthodontic treatment. In this context, the mediating role of psychological resilience in the predictive relationship between emotional reactivity, intolerance of uncertainty and psychological maladjustment was examined. It is aimed to contribute to the expansion of this perspective and to the limited number of studies in the literature on the psychological consequences of orthodontic treatments by analyzing personal risk factors and protective factors by addressing the negative psychological effects on children since orthodontic treatments require a long-term treatment planning.
Within this scope, the research questions to be answered are as follows; 1. Are emotional reactivity and intolerance of uncertainty a signi cant predictor of psychological maladjustment in children and adolescents receiving orthodontic treatment?
2. Is there a mediating role of psychological resilience between emotional reactivity, intolerance of uncertainty and psychological maladjustment in children and adolescents receiving orthodontic treatment?

Participants
Participants of the study consisted of 543 children aged between 10 and 18 (m = 15.30, Sd = 2.14) who were accessed through systematic and convenient sampling methods among the patients who were still being treated in the Orthodontics clinic of Faculty of Dentistry, Atatürk University. 73.6% of the participants are females and 26.4% are males. 56.42% of the participants receive xed treatments, 18.9% orthognathic surgery, 13% xed treatments with extraoral device and 11.7% mobile orthodontic appliances. In terms of the timing of the treatment, 84.8% of the participants have continued their treatment for at least 3 months, and the treatment of 15.2% has just started. The reasons for starting the treatment are to straighten crooked teeth in 49.7%, xing the jaw and facial appearance in 22.8%, the more aesthetic and beautiful appearance in 18.9%, the improvement of speech in 7.2% and 7% of them started the treatment process for reasons other than these.

Measures
The Emotional Reactivity Scale: It was developed by Nock, et al. 10 to measure the emotional intensity experienced in the face of situations that arise in interpersonal relationships and the reactivity expressed in these intense emotional situations and it was adapted to Turkish culture by Seçer et al. 20  .036, CFI: .98) showed that the three-factor structure consisting of 21 items has a good level of t (sample questions are, "I felt scared without a valid reason and I was worried about situations where I would panic and make myself stupid"). The scores obtained from the scale range from 21 to 84, and high scores indicate high levels of depression, anxiety and stress symptoms.

Procedure and Data Analyses
The research process started with the approval of the Ethics Committee of Faculty of Dentistry, Atatürk University for research compliance. The data collection process was carried out using online tools due to COVID-19 social distance restrictions. In this context, children who were registered in the hospital database and whose orthodontic treatment continues were determined. In the second stage, the junior doctors who followed the treatment processes of these children were contacted to reach the children and their parents, and their consent was obtained for voluntary participation. The parents of the children who volunteered to participate were asked to help their children complete the measurement tools by sending its link via e-mail and WhatsApp-like applications. In this context, the online data collection link prepared through Google Documents was used (available from https://forms.gle/xJRQ3krHVo5cfDzu7). Additional explanations on volunteering and data privacy are also included in this link. In addition, information regarding that they can withdraw from lling the questionnaire at any time was added. The data collection process was completed within 20 days. Data collection and compilation procedures were carried out by three different specialists from dentistry, orthodontic treatments and psychology. However, as it was determined that the data of 21 participants in the data set did not meet the normalityhomogeneity criteria, they were excluded from the analysis.
During the analysis process, structural equation analyzes were carried out with the LISREL 9.2 software.
In the analysis process, the con rmatory measurement model was tested at the rst stage and it was determined that the designed model ts well (χ2/sd=1.60; REMSEA: .071, RMR: .073, SRMR: .073, NFI: .

Results
Three different structural models were tested in line with the research questions. Each model and its ndings are presented below. In this context, the research hypothesis, which was designed as "Emotional reactivity and intolerance of uncertainty predict psychological adjustment skills in children receiving orthodontic treatment" was tested as Model 1. In this model, high emotional reactivity and high intolerance of uncertainty are expected to positively predict psychological adjustment skills in children receiving orthodontic treatment. Findings related to Model 1 are presented in Fig. 1.
Considering the t index values χ 2 (44,26/34) = 1,30; CFI = .97; TLI = .96; NFI = .94;GFI = .93) for the model tested in Fig. 1, it can be said that all of the implicit variables in Model 1 have a signi cant relationship with the observed variables (p < 0.001) they represent. In this sense, it is seen that emotional reactivity (β = .41, p < .01, 17%) and intolerance of uncertainty (β = .47, p < .01, 22%) are positive and signi cant predictors of psychological adjustment skills in children receiving orthodontic treatment. Although the relationship patterns determined between the variables are signi cant and high, it is recommended to include the variables in structural equation models that are likely to mediate these relationships and test their effect. Therefore, whether it mediates the relationship patterns determined in Model 1 was analyzed by including the psychological resilience variable in the model. In this process de ned as Model 2, the direct and indirect effects of emotional reactivity and intolerance of uncertainty on psychological adaptation skills were examined. In this sense, the research hypothesis, constructed as Model 2, was expressed as "How did the direct prediction effect of emotional reactivity and intolerance of uncertainty on psychological adaptation skills in children receiving orthodontic treatment change after the inclusion of resilience in the model?", and the ndings obtained are presented in Fig. 2.
When Model 2, in which mediation relations is tested, is examined, it is seen that the mediation of psychological resilience is signi cant and the t indices are su cient. The general rule in mediation relations is that when the "mediator variable" is included in the model, a signi cant change occurs in the direct prediction coe cients obtained in Model 1. When Model 2 is examined, there is no signi cant change in the predictive coe cients of emotional reactivity and intolerance of uncertainty in Model 1 on psychological maladjustment. However, striking point in Model 2 is that the relationship between psychological resilience and psychological adjustment is not signi cant although emotional reactivity (β = .47, p < .01, 22%) and intolerance of uncertainty (= .47, p < .01, 22%) negatively predicted psychological resilience. Considering that this, which is considered as Type II error, stems from the direct prediction paths in the model, a new model that tests the full mediator relations was structured. In this model de ned as Model 3, the answer was sought for the research question expressed as "Does psychological resilience fully mediate the relationship between emotional reactivity and intolerance of uncertainty and psychological adjustment?" Findings regarding this model are presented in Fig. 3. In this model, it is aimed to prevent Type II error and analyze the real relationship patterns between the variables by removing the direct paths from emotional reactivity and intolerance of uncertainty from the model. When Fig. 3 is examined, it is seen that the model that tests the full mediation of psychological resilience in children receiving orthodontic treatment is well adapted and signi cantly differentiates from Model 2. In addition, there is a signi cant improvement in the prediction coe cients and t indices between variables compared to Model 2 (χ 2 (299,32/205) = 1,46; CFI = .98; TLI = .97; SRMR = .048; RMSEA = .046). When the ndings obtained regarding the mediation model were examined, it was found that emotional reactivity (β = − .67, p < .01, 45%) and intolerance of uncertainty ( = − .24, p < .01, 6%) negatively predicted psychological resilience and it is also seen that they predict psychological adjustment through resilience ( = − .32, p < .01, 10%). Findings obtained in Model 3 contain signi cant differences compared to Model 2. The rst striking difference is that there is a signi cant increase in the predictive coe cients of emotional reactivity and intolerance of uncertainty on psychological resilience compared to Model 2. The second important difference is that although the predictive effect of psychological resilience on psychological adjustment is insigni cant in Model 2, a serious change has occurred in this predictive coe cient in Model 3 (β= − .78, p < .01, % 60). In this context, it can be said that psychological resilience has a fully mediating function in the relationship between emotional reactivity and intolerance of uncertainty and psychological adjustment in line with the ndings in Model 3.

Conclusion And Discussion
In line with the ndings obtained from the study, it was determined that children and adolescents receiving orthodontic treatment have a high probability of developing psychological maladjustment (depression, anxiety, stress), emotional reactivity and intolerance of uncertainty are risk factors, and psychological resilience stands out as an important variable that protects children and adolescents against this risk.
Research results show that emotional reactivity is a predictor of psychological maladjustment in children and adolescents receiving orthodontic treatment, and high emotional reactivity creates a signi cant risk for psychological maladjustment. This nding, which is parallel with the related literature, is thought to be signi cant 3,10,11 since such factors that orthodontic treatments are long-term, the treatment involves a troublesome process, and the apparatus used affects the appearance can possibly trigger psychological symptoms. Therefore, it can be thought that high emotional reactivity may increase the psychological symptoms in these children and cause the treatment to be negatively affected. It is even considered that emotional reactivity may have a negative function at the point of interrupting and disrupting the treatment.
Another important nding is the results showing that intolerance of uncertainty is a predictor of psychological maladjustment in children and adolescents receiving orthodontic treatment. It seems more likely to develop psychological symptoms in children with a high level of intolerance of uncertainty 3,14,15 .
It can be said that children with low tolerance of uncertainty will develop more negative reactions in emotional, cognitive and behavioral terms and may disrupt the process considering the factors affecting the duration and success of orthodontic treatment. Therefore, intolerance of uncertainty and emotional reactivity, which are prominent risk factors in orthodontic treatments, are considered to be bene cial as variables that may affect the course of the treatment.
The most striking nding of the study is about the protective role of psychological resilience. The ndings indicate that children who receive orthodontic treatment and have high psychological resilience are less likely to develop psychological symptoms. This nding, which coincides with the related literature 2,29,30, indicates that psychological resilience may play an important role in reducing the risk of emotional reactivity and intolerance of uncertainty in orthodontic treatment and preventing children from developing psychological symptoms. In this sense, it is considered that there is a need to consider the psychological processes at every stage of orthodontic treatment procedure and to make a general evaluation in terms of psychological protective and risk factors since it is thought that such evaluations will provide important contributions both in preventing the development of treatment-related symptoms and ensuring the continuity of the treatment.

Limitations And Future Research
The ndings of this research should be evaluated in the context of its limitations. The research was conducted only in a relational and cross-sectional context due to the negativities created by the epidemic. In addition, data collection was completed online for the same reason. Their effect on research results should be considered.
Why this paper is important to paediatric dentists 1. It is believed that the results of the research will contribute to the expansion of the perspective on orthodontic treatments carried out with children and young people in the national and international arena 2. It is considered that these ndings may contribute to the expansion of pediatric dentists' perspectives on the secondary outcomes of orthodontic treatment practices 3. It will be able to contribute to the expansion of the perspective regarding the psychological consequences of orthodontic treatments. 4. In fact, based on analyzing the protective and risk factors for the ndings and ndings regarding psychological maladjustment in children receiving orthodontic treatment, it is thought that it can contribute to the development of action plans for making psychological intervention and therapy approaches a dimension of orthodontic treatment processes and to draw the attention of researchers to applications in this direction.  Model 3