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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2018  |  Volume : 36  |  Issue : 4  |  Page : 407-409

Does attachment profiles influence child's behavior in pediatric dental clinic?

1 Departments of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Departments of Pedodontics and Preventive Dentistry, Priyadarshani Dental College and Hospital, Tiruvallur, Tamil Nadu, India

Date of Web Publication16-Oct-2018

Correspondence Address:
S VS G Nirmala
Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore - 524 003, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_1169_17

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Although it was believed that attachment was due to the food provided by the parent figure, later it was proved that attachment is because the child considers parent figure as secure base. Hence, when a child feels distressed in dental operatory, the type of attachment pattern will determine the behavior of a child. This, in turn, could determine the weather parental presence is needed or not in dental operatory. Hence, attachment patterns could affect the quality of dental treatment delivered.

Keywords: Attachment, behavior, children, dental operatory, mother

How to cite this article:
G Nirmala S V, Dasaraju RK, Sivakumar N. Does attachment profiles influence child's behavior in pediatric dental clinic?. J Indian Soc Pedod Prev Dent 2018;36:407-9

How to cite this URL:
G Nirmala S V, Dasaraju RK, Sivakumar N. Does attachment profiles influence child's behavior in pediatric dental clinic?. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2022 Nov 29];36:407-9. Available from: http://www.jisppd.com/text.asp?2018/36/4/407/243445

   Introduction Top

Attachment is the tendency of infants and young children to rely on a parent figure for comfort and support when frightened stressed or ill.[1] Attachment bond is long-term stable tendency to seek out a selected parent figure in terms of stress. Although attachment and bonding were synonymously used, they are not the same. “Bonding” concept was developed by Klaus and Kennell that implies parent-child 'bonding' which depends on skin-to-skin contact. This concept of “bonding” was proven to be erroneous and to have nothing to do with attachment.[2]

Parents' sensitivity and response to a child's attachment signals are determinant of attachment security.[3],[4] However, genetic factors have limited role in the development of attachment in infants and preschooler. There are two main theories explaining attachment.

Two main theories

  1. Learning/behaviorist theory, e.g., Dollard and Miller (1950) – Children bond to mother due to feeding, combine classic conditioning (associate feeder with comfort of being fed), and operant conditioning (repeat behavior in order to get things they want
  2. Evolutionary theory of attachment: e.g., Bowlby, Harlow, and Lorenz imprinting theory – Children bonding to mother are due to safety and security.

Attachment influence on parental presence in operatory

The parental presence in the dental operatory during a child's treatment and influence on behavior of children is still a debatable issue. Many demonstrated that a child's behavior is unaffected by the parental presence or absence in the dental operatory; however, the presence of mothers proved to be beneficial.[5]

When given a choice, parents wish to be present in the dental operatory, it is due to the attachment of children to their parents, and the same attachment even makes the child to seek parental presence. Peretz and Zadik done a study on 104 parents completed a questionnaire regarding their presence in the operatory. Most of the parents (70.2%) expressed a wish to be present in the operatory.[6] Arathi and Ashwani also conducted a questionnaire study answered by 1350 parents and concluded that 78.3% of whom expressed their willingness to be present with a child during dental procedures.[7] Crowley et al. studied the preference of parents of 8-year-old school children in Ireland in relation to accompanying their children during dental procedures and concluded that if given a choice, the majority of parents (67%) would prefer to accompany their child when receiving dental treatment.[8] In the literature, it was showed that majority of Saudi parents studied preferred to stay with their children during treatment.[9]

It was supported by the attachment theory of John Bowlby, which states that children seek the proximity of caregivers/parents whenever they anticipate adverse situations. John Bowlby and Mary Ainsworth work on attachment theory presented different attachment profiles. Mary Ainsworth and Wittig (1969) proposed three attachment styles based on strange situation procedure, namely “secure,” “avoidant insecure,” and “ambivalent insecure;” later Main and Solomon (1990) added the fourth style known as “disorganized insecure” styles of attachment.[10] The characteristics of these different attachment styles were mentioned in [Table 1].
Table 1: Attachment styles and characteristics

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The main characteristics of attachment are proximity maintenance with caregiver, feeling a caregiver/parent as a secure base and safe heaven, showing distress when separated from parent/caregiver.[11] These characteristics warrant the parental presence in the dental operatory when dealing with children of young age, and these characteristics may change with the age of a child and may not hold good for older children, as children of age <5 years cannot tolerate separation from the parents, due to separation anxiety and stranger anxiety. Conversely, a study reported that parental presence or absence does not affect an Iranian 5-year-old child's cooperation on the first and second dental visit (Hossien Afshar). However, in this study, the attachment characteristics were not addressed.[12]

The pattern of attachment changes with the age of a child. Rudolph Schaffer and Peggy Emerson (1964) proposed attachment stages (depending on age) as, 4 types.[13]

  1. Preattachment (0–3 months)
  2. Indiscriminate attachment (1 1/2–7 months)
  3. Discriminate attachment
  4. Multiple attachment.

The level of attachment of children to caregivers/parents is in turn dependent on the age of a child. Few studies report that the behavior of a child in parental presence or absence in dental operatory is dependent on age.[14],[15],[16] Hence, the parental presence in dental operatory is determined to extend by the age of a child. However, exclusion of the parent allowed the dentist to develop an amicable relationship with the child–patient without parental interference.[17] Dentists also argue that parental presence can be a distraction for both the child and the health-care professional and hampers delivery of quality dental care.[18]

Handa et al. concluded that from the parent's perspective, their protective nature wants them to be with their child so that they can make their child feel safe. However, for the dentist to form a holistic bond with the patient, certain factors need to be kept in mind that define the parental attitudes for better treatment of his patient.[19] Shaw and Routh studied 18-month-old and 5-year-old children receiving immunizations with and without the presence of their mothers and found that behavior was worse in both age groups when the mother was present.[20]

   Conclusion Top

Attachment of children with parents plays a role in children behavior in dental operatory which in turn determines the necessity of parental presence in dental operatory or not in children below 8 years of age. As attachment is age dependent, operator should decide upon parental presence in operatory depending on their co-operative levels.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Miller PM, Commons ML. The benefits of attachment parenting for infants and children: A behavioral developmental view. Behav Dev Bull 2010;10:1-14.  Back to cited text no. 1
Klaus MH, Kennell JH. Maternal-Infant Bonding: The Impact of Early Separation or Loss on Family Development. St. Louis: Mosby; 1976.  Back to cited text no. 2
Ainsworth MD, Blehar MC, Waters E, Wall S. Pattern of attachment: A psychological study of the strange situation. Hillsdale NJ: Lawrence Erlbaum Associates; 1978.  Back to cited text no. 3
De Wolff MS, van Ijzendoorn MH. Sensitivity and attachment: A meta-analysis on parental antecedents of infant attachment. Child Dev 1997;68:571-91.  Back to cited text no. 4
Cox IC, Krikken JB, Veerkamp JS. Influence of parental presence on the child's perception of, and behaviour, during dental treatment. Eur Arch Paediatr Dent 2011;12:200-4.  Back to cited text no. 5
Peretz B, Zadik D. Attitudes of parents towards their presence in the operatory during dental treatments to their children. J Clin Pediatr Dent 1998;23:27-30.  Back to cited text no. 6
Arathi R, Ashwini R. Parental presence in the dental operatory-parent's point of view. J Indian Soc Pedod Prev Dent 1999;17:150-5.  Back to cited text no. 7
Crowley E, Whelton H, O'Mullane D, Cronin M, Kelleher V, Flannery E, et al. Parents' preference as to whether they would like to accompany their child when receiving dental treatment – Results from a national survey. J Ir Dent Assoc 2005;51:23-4.  Back to cited text no. 8
Abushal M, Adenubi JO. Attitudes of Saudi parents toward separation from their children during dental treatment. Saudi Dent J 2009;21:63-7.  Back to cited text no. 9
Ainsworth M, Wittig B. Attachment and exploratory behavior of one-year-olds in a strange situation. Determinants of Infant Behavior. Vol. 4. London, UK: Methuen; 1969. p. 113-36.  Back to cited text no. 10
Bowlby J. Attachment and Loss. Attachment. Vol. 1. London: The Hogarth Press and the Institute of Psycho-Analysis; 1969. p. 1-401.  Back to cited text no. 11
Afshar H, Baradaran Nakhjavani Y, Mahmoudi-Gharaei J, Paryab M, Zadhoosh S. The effect of parental presence on the 5 year-old children's anxiety and cooperative behavior in the first and second dental visit. Iran J Pediatr 2011;21:193-200.  Back to cited text no. 12
Schaffer HR, Emerson PE. The development of social attachments in infancy. Monogr Soc Res Child Dev 1964;29:1-77.  Back to cited text no. 13
Pfefferle JC, Machen JB, Fields HW, Posnick WR. Child behavior in the dental setting relevant to parental presence. Pediatr Dent 1982;4:311-6.  Back to cited text no. 14
Marzo G, Campanella V, Albani F, Gallusi G. Psychological aspects in paediatric dentistry: Parental presence. Eur J Paediatr Dent 2003;4:177-80.  Back to cited text no. 15
Fenlon WL, Dabbs AR, Curzon ME. Parental presence during treatment of the child patient: A study with British parents. Br Dent J 1993;174:23-8.  Back to cited text no. 16
Wright GZ, Starkey PE, Gardner DE, editors. Managing Children's behavior in the dental office. In: Parentchild Separation. St. Louis: C.V. Mosby Co.; 1983. p. 57-74.  Back to cited text no. 17
Piira T, Sugiura T, Champion GD, Donnelly N, Cole AS. The role of parental presence in the context of children's medical procedures: A systematic review. Child Care Health Dev 2005;31:233-43.  Back to cited text no. 18
Handa S, Thakar S, Marya N, Dutta A, Prabhakar I, Deol S. Attitudes of parents toward separation from their children during dental treatment in Delhi NCR. Int J Prev Clin Dent Res 2014;1:23-6.  Back to cited text no. 19
Shaw EG, Routh DK. Effect of mother presence on children's reaction at aversive procedures. J Pediatr Psychol 1982;7:33-4.  Back to cited text no. 20


  [Table 1]


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