兒童牙科害怕/焦慮之探討：CFSS-DS篩檢量表中文版之修訂、盛行率與相關因素

Dental Fear/Anxiety in Children: Chinese version of CFSS-DS Screening Scale, Prevalence and Related Factors

李貞儀(Chen-Yi Lee)

指導教授 ： 黃純德 ； 張永源

高雄醫學大學/口腔醫學院/牙醫學研究所/博士(2008年)

https://doi.org/10.6832/KMU.2008.00084

摘要

背 景：

許多人對於牙科治療都有或多或少的不安，尤其是對於有牙科焦慮的兒童來說，牙科治療可以是一個很可怕的經驗。對牙科的害怕和焦慮被評比為今日兒童牙科中最麻煩的問題之一。牙科害怕/焦慮引起的不合作和擾亂行為，經常阻礙牙科醫生的治療，且因焦慮而引起的逃避看牙科行為也會影響兒童的口腔健康。台灣目前對於兒童牙科害怕/焦慮之研究付之闕如，有其探討之必要。

本研究之主要重點為：
一、進行兒童害怕調查表之牙科分量表(Children’s Fear Survey Schedule-Dental Subscale; CFSS-DS)的中文修訂。
二、以中文版CFSS-DS來估計高雄地區5~8歲孩童對於看牙科有高度害怕/焦慮感之盛行率。
三、進行中文版CFSS-DS之探索性因素分析(exploratory factor analysis; EFA)。
四、進行兒童牙科害怕/焦慮相關預測因素之分析。

方 法：

本研究共分三部分進行：

第一部分為CFSS-DS之中文修訂和兒童牙科害怕/焦慮之盛行率估計。CFSS-DS進行中英互譯後，以96位牙科門診的兒童進行預試(pretest)，以其臨床觀察紀錄為效標(criterion)，並以receiver operating characteristic (ROC) curve來界定中文版CFSS-DS的臨界分數(cut-off score)。然後，以中文版CFSS-DS進行校園內5~8歲學童的牙科害怕/焦慮程度篩檢，被選擇的學校是經過依行政區、年齡層和性別進行的分層隨機抽樣所選出，最後回收有效樣本數為3,597份。

第二部分為中文版CFSS-DS之探索性因素分析。研究樣本為第一部分所收集之校園樣本中以隨機抽樣抽出的1,819位學童的得分。以主成份分析(principal components method)加斜交轉軸(promax rotation)的方式進行一階因素分析(first-order factor analysis)，並以SLS(Schmid-Leiman solution)的方式進行二階因素分析(second-order factor analysis)。

第三部分為兒童牙科害怕/焦慮之相關原因探討。研究對象為從高醫兒童牙科門診收集到的247名兒童的資料(2~10歲)，由觀察者紀錄兒童在牙科治療中的焦慮反應程度和不合作程度，並請主要照顧者(通常是母親)填寫問卷，問卷內容包含：CFSS-DS、牙科就醫行為、過去的牙科經驗、可能的制約途徑、母親的牙科害怕程度。以逐步淘汰複迴歸分析的方式分別找出CFSS-DS得分、臨床焦慮程度及不合作行為的預測因素。

結 果：

第一部分，中文版CFSS-DS的臨界分數定為38/39分，敏感性(sensitivity)為0.857，特異性(specificity)為0.882，ROC曲線下面積為0.912。高雄市5~8歲學童的高度牙科害怕/焦慮之預估盛行率為20.6%。CFSS-DS得分隨年齡增加而降低，而小學男童的得分顯著較低。

第二部分，本研究發現中文版CFSS-DS有三個一階因素和一個二階因素，一階因素分別被定義為「對牙科相關項目的害怕」、「對醫學相關項目的害怕」和「對可能成為受害者的害怕」；二階因素被定義為「牙科害怕/焦慮」，此二階因素可以解釋整個高階因素結構的大部分變異數。

第三部分，本研究發現CFSS-DS得分與臨床焦慮程度分別有不同的預測因素，但是年齡在4歲以下以及第一次看牙醫時能夠合作順從，是兩者之間重要的共同預測因素。此外，CFSS-DS得分的其他預測因素包括：母親的牙科害怕程度、第一次看牙醫時疼痛難忍、在固定地點看牙醫。臨床焦慮程度的其他預測因素為：第一胎、有固定的牙醫師，和CFSS-DS得分。最後，能夠預測不合作程度的唯一一個預測因素為臨床焦慮程度。

結 論：

(1)以ROC curve的方式來界定CFSS-DS得分的臨界分數是可行且實用的。
(2)台灣地區5~8歲兒童的高度牙科害怕/焦慮之預估盛行率很高，可能與口腔衛生教育之不足及高齲齒率有關。
(3)以CFSS-DS所測量之兒童的「牙科害怕/焦慮」，可能是一個高階因素結構，具備一個二階因素和三個一階因素。
(4)兒童的牙科害怕，與其實際在接受牙科治療時的焦慮反應，是具有許多不同因素的動態過程。
(5)主觀疼痛經驗的直接制約，在牙科害怕的形成上，比客觀途徑更為重要。間接制約途徑，在本研究樣本中並沒有顯著的影響力。

關鍵字

牙科害怕 ； 牙科焦慮 ； 盛行率 ； ROC曲線 ； 兒童 ； 探索性因素分析 ； 高階因素分析 ； 預測因素

並列摘要

Objectives:
Many people experience discomfort to a greater or lesser degree about the prospect of dental treatment. Dental treatment can be a terrible experience, especially for children with dental anxiety. Dental fear has been singled out as one of the most troublesome problems facing paediatric dentistry today. Children with dental fear may avoid visiting dentists; therefore, their oral health protection is often compromised. However, the etiology of dental fear is still not entirely understood.

The purposes of this study were:
(1)To modify the Chinese version Children’s Fear Survey Schedule- Dental Subscale (CFSS-DS)
(2)To estimate the prevalence of dental anxiety among 5- to 8-year-old children in Kaohsiung City, Taiwan.
(3)To explore the higher-order factor structure of the parental Chinese version of the CFSS-DS with a large sample of young children in Taiwan.
(4)To investigate the dental visiting habit, the previous dental experiences, the conditioning pathway and the clinically-related predictors of dental fear in children.

Methods:
Study1
The Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS) was translated into Chinese, and a receiver operating characteristic (ROC) curve was made based on criteria determined from pretest clinical observations of a sample population to set a cutoff score. Then, the parental CFSS-DS was used as a screening tool to survey the dental anxiety levels of 5- to 8-year-old children at kindergartens and elementary schools in Kaohsiung City, Taiwan. Participants were selected by stratified random sampling. The stratification was done by geographic district, age group, and sex. Total of 3,597 valid questionnaires were collected.

Study2
A first-order factor analysis was performed using the principal components method with promax rotation, and a second-order factor was obtained by applying the Schmid-Leiman solution (SLS).

Study3
The dental history of 247 children (2-10 years old) was obtained when they came to a dental clinic for treatment. The level of dental fear in these children was assessed using the Dental Subscale of the Children’s Fear Survey Schedule (CFSS-DS). Observers rated the clinically anxious responses and uncooperative behavior toward dental treatment in these children. Three stepwise regression analyses were performed to determine significant predictors of CFSS-DS score, clinically anxious responses, and uncooperative behavior of children respectively.

Results:
Study1
The Chinese version of the CFSS-DS had an optimal cutoff score of 38/39 (sensitivity was 0.857, specificity was 0.882) with an area under the ROC curve of 0.912. The estimated prevalence of dental anxiety among 5- to 8-year-old children in Kaohsiung City was 20.6 percent. The dental anxiety score was found to decrease as age increased; primary school boys had significantly lower scores.

Study2
The present study found three first-order factors, defined as: (1) fear of dental aspects, (2) fear of medical aspects, and (3) fear of potential victimization. The second-order factor defined as “dental fear” accounted for most of the variance in the second-order factor structure. The results of higher-order factor analysis according to different gender or age levels were identical.

Study3
We found that the CFSS-DS score and clinical anxiety have different predictors, but age ≤3.99 years old and cooperativeness in the first dental visit were important predictors for both the CFSS-DS score and the clinical anxiety. Furthermore, the other predictors of the CFSS-DS score were maternal dental fear, unbearable pain during the first dental visit, and visiting dentists in a regular dental clinic; and the other predictors of the clinical anxiety were first-born, regular-dentist, and CFSS-DS score. Finally, the only significant predictor for uncooperative behavior was clinical anxiety.

Conclusions:
Study1
The prevalence of dental anxiety was found to be high for 5- to 8-year-old Taiwanese children. The study’s findings point to the urgent need for preventive health education and intervention programs in Taiwan to promote children’s oral health and reduce dental anxiety.

Study2
A higher-order factor structure consisting of a single second-order factor and three first-order factors was extracted, giving a fuller understanding of the CFSS-DS.

Study3
Children’s dental fear and their anxious response during dental treatment were dynamic processes that consisted of many different factors. The direct conditioning of subjective experience of pain was more important than the objective pathway of child dental fear, and the indirect conditioning does not seem influential in this study sample.

並列關鍵字

dental fear ； dental anxiety ； prevalence ； ROC curve ； children ； exploratory factor analysis(EFA) ； higher-order factor analysis ； predictors

參考文獻

1. Alvesalo, I., Murtomaa, H., Milgrom, P., Honkanen, A., Karjalainen, M., & Tay, K. M. (1993). The Dental Fear Survey Schedule: a study with Finnish children. International Journal of Paediatric Dentistry, 3(4), 193-198.

2. American Academy of Pediatric Dentistry. (1997). Guidelines for behavior management. Pediatric Dentistry, 18, 40-44.

3. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association.

4. Andlaw, R. J., & Rock, W. P. (1996). Manual of pediatric dentistry. Edinburgh: Churchill Livingstone.

5. Arnrup, K., Broberg, A. G., Berggren, U., & Bodin, L. (2002). Lack of cooperation in pediatric dentistry- the role of child personality characteristics. Pediatric Dentistry, 24, 119-127.