HHS Public Access Author manuscript Author Manuscript
Pediatr Dent. Author manuscript; available in PMC 2017 April 15. Published in final edited form as: Pediatr Dent. 2016 October 15; 38(5): 425–431.
Caregiver Illness Perception of Their Child’s Early Childhood Caries: A Case-Control Study Mary Beth Slusar, PhD and Research Associate, Community Dentistry, Case Western Reserve University School of Dental Medicine, 10900 Euclid Ave., Cleveland, OH 44106-4905, Telephone: 216-368-2833, Fax: 216-368-1298
Author Manuscript
Suchitra Nelson, PhD Professor, Community Dentistry, Case Western Reserve University School of Dental Medicine, 10900 Euclid Ave., Cleveland, OH 44106-4905, Telephone: 216-368-3469 Fax: 216-368-1298
Abstract Purpose—This case-control study evaluated the association between parent/caregivers’ illness perception and early childhood caries (ECC).
Author Manuscript
Methods—Parent/caregivers of children less than six years old were recruited at the dental clinic of an urban children’s hospital (June 2013-September 2015). Cases were caregivers of children with ECC; controls were caregivers of children without ECC. Caregivers completed the Illness Perception Questionnaire-Revised for Dental (IPQ-RD) assessing cognitive (identity, consequences, control, timeline, illness coherence, cause) and emotional representations of dental caries. Twelve IPQ-RD construct-specific summary scores were calculated; higher scores represented less accurate perception. Logistic regression models examined the relationship between IPQ-RD constructs and ECC. Results—The sample included a total of 165 parent/caregivers: 54 (33 percent) of children without ECC; 111 (67 percent) of children with ECC. Two of twelve constructs were related to ECC status. Controlling for caregiver age, education, race/ethnicity and child age, caregivers of children with ECC had less accurate perception of the consequences of dental caries (OR=2.24; 95% CI: 1.07–4.69) and more accurate perception of the controllability of caries (OR=0.29; 95% CI: 0.11–0.76), compared to caregivers of children without ECC. Conclusion—Our results suggest that clinicians should emphasize the consequences and controllability of ECC to help caregivers self-manage their child’s oral health.
Author Manuscript
Keywords Dental Caries; Caregivers; Perception
INTRODUCTION Recent national estimates indicate that early childhood caries (ECC) remains a persistent problem in the U.S. with prevalence at 23 percent and untreated caries at 10 percent among two to five year olds1. Poor and minority children are disproportionately more likely to have untreated tooth decay, or unfilled cavities1. While 45 percent of all children visited the
Slusar and Nelson
Page 2
Author Manuscript
dentist in 20112, median dental utilization for Medicaid-enrolled children was only 33 percent3. Inaccurate beliefs or lack of knowledge about their child’s oral health (e.g. importance of primary teeth, tooth brushing) and the effectiveness of preventive care (e.g. timing of first dental visit) have been identified as caregiver barriers to promoting healthy oral hygiene practices in their child or seeking dental care for their child4–11 which subsequently can lead to ECC12–15.
Author Manuscript
The Common Sense Model of Self-Regulation (CSM), a useful but underutilized framework, posits that a patient’s (or their caregiver’s) beliefs about their illness and its treatment along with their emotional response affect health outcomes, often through coping strategies16–17. To self-manage their chronic illness, patients (or caregivers) base their illness perception on various sources of information: from a health care provider or relative, cultural knowledge of the illness, and illness threat from past and current experiences with the disease18. The Revised Illness Perception Questionnaire (IPQ-R)16 has been modified for various medical19–20 and psychological21 conditions. But, little attention has been paid to the illness perceptions of the individuals who care for them (i.e. spouses, parents, relatives) or to consideration of dental conditions as chronic illnesses. Dental caries is similar to other chronic conditions in children in that it requires adequate self-management strategies by their parent/caregiver. The Illness Perception Questionnaire-Revised for Dental (IPQ-RD)22 is a newly adapted version of the IPQ-R, modeled after versions used in medicine23.
Author Manuscript Author Manuscript
Incorporating caregivers’ cognitive and emotional representations of their child’s dental caries, the IPQ-RD improves upon existing caregiver oral health measures, e.g. oral health knowledge and attitudes and OHRQoL, that use health behavior theories (e.g. social cognitive theory, health belief model). While oral health knowledge and attitudes measure caregivers’ awareness of facts24–25, they do not assess how those facts are processed. OHRQoL measures, such as the Early Childhood Oral Health Impact Scale (ECOHIS)26 and Pediatric Oral Health-Related Quality of Life (POQL) instrument27, are caregivers’ assessment of the consequences of dental caries and treatments on their child and family, but with a narrow focus on a single dimension. By incorporating multiple cognitive dimensions with emotional processes, the IPQ-RD provides a more complete and dynamic measure of caregivers’ understanding of their child’s dental caries to influence coping and health outcomes. Recently the CSM framework has been used to develop a new theory-based referral approach to improve children’s dental access by addressing caregiver misperception regarding primary teeth and the chronicity of caries28. Except for this study demonstrating the clinical utility of the CSM framework 28, little work has been done to understand differences in the perception of caregivers whose children do and do not have dental caries. Without such empiric data, behavioral interventions to address this misperception will be difficult. Therefore, the aims of this study were to: (1) examine the factor structure of the IPQ-RD “cause” dimension to identify salient cause factors to be included in aim 2; (2) compare the illness perception (cognitive: identity, consequences, cause, control, timeline, illness coherence; and emotional representations) of parent/caregivers of children less than six years old with and without ECC. We hypothesized that children with ECC will have caregivers
Pediatr Dent. Author manuscript; available in PMC 2017 April 15.
Slusar and Nelson
Page 3
Author Manuscript
with less accurate illness perception about dental caries compared to children without ECC, after controlling for relevant covariates.
METHODS Study design and participants
Author Manuscript
A case-control study design was used. Parent/caregivers of children under six years were recruited from the dental clinic at an urban children’s hospital in Cleveland, Ohio from June 2013 to September 2015. Out of 219 caregivers who were approached in the waiting room, 83 percent consented to participate in the study, and 165 caregivers were enrolled (i.e. 16 were excluded due to eligibility criteria or missing data). Caregivers were not asked at the time of recruitment if their child had dental caries. They were enrolled before their child saw the dentist and given two questionnaires to complete: IPQ-RD and Caregiver Questionnaire. Once data was abstracted from their child’s dental chart (i.e. after their child’s dental appointment), caregivers were assigned accordingly to the case or control group. Cases were caregivers of children with ECC (total number of decayed, missing, filled primary teeth: dmft equal to or greater than one), and controls were caregivers of children without ECC (dmft equal to zero). Measurement of early childhood caries adhered to the American Academy of Pediatric Dentistry (AAPD) guidelines. The study was approved by the University Hospitals Case Medical Center Institutional Review Board (Cleveland, Ohio), and informed consent was obtained from caregivers (parent or legal guardian). Data collection and measures
Author Manuscript
Data abstraction—Child data—total number of teeth and dmft—were abstracted from dental charts. Clinical examinations were performed by residents or faculty in pediatric dentistry.
Author Manuscript
Illness Perception Question-Revised for Dental (IPQ-RD)—The IPQ-RD is comprised of 10 CSM constructs (33 items) assessing caregivers’ cognitive and emotional representations of their child’s dental caries. The psychometric properties of the IPQ-RD have been tested and validated22 without the inclusion of the cause construct as recommended previously16. The cognitive dimensions, or constructs, include the following: identity [two items]: caregiver’s perception of the intensity of symptoms associated with their child’s dental caries (e.g. “Cavities is an illness with many symptoms.”); consequences-child [seven items]: beliefs about the serious consequences of caries on their child’s daily activities (e.g. “Cavities in my child has a big effect on his/her school work.”); consequences-caregiver [five items]: beliefs about the serious consequences of their child’s caries on their own life (e.g. “Cavities in my child has a big effect on how others see me.”); control-child [four items]: beliefs about whether their child’s caries and its symptoms can be prevented, improved, and/or kept under control by their child’s actions (e.g. “What my child does decides if his/her cavities get better or worse.”); control-caregiver [four items]: beliefs about whether their child’s caries can be prevented, improved, and/or kept under control by their own actions (e.g. “There is a lot I can do to prevent cavities in my child.”); timelinechronic [two items]: beliefs about the chronicity and duration of their child’s caries (e.g. “Cavities in my child are likely to be long-lasting rather than short-term.”); timeline-cyclical
Pediatr Dent. Author manuscript; available in PMC 2017 April 15.
Slusar and Nelson
Page 4
Author Manuscript
[two items]: beliefs about the predictability of their child’s caries and its symptoms (e.g. “There will be times when my child’s cavity symptoms get worse and times when they get better.”); illness coherence [two items]: whether the caregiver has a clear understanding of their child’s caries and its symptoms (e.g. “My child’s cavity symptoms are not confusing to me.”); and cause [with 11 sub-items]: caregiver’s perception of the causes of their child’s caries (e.g. “Stress or worry caused my child’s cavities.”). Emotional representations [four items] is an assessment of the caregiver’s emotional response to their child’s dental caries (e.g. “Seeing my child with cavities makes me feel angry.”).
Author Manuscript
Each item was scored on a 5-point Likert scale (1=strongly agree, 2=agree, 3=neither agree nor disagree, 4=disagree, 5=strongly disagree) with a higher score representing less accurate perception. IPQ-RD construct-specific summary scores were calculated from the mean rather than the sum of items in each construct for each caregiver. For example, if the values of a caregiver’s responses for the four emotional representations items were 4, 5, 4, and 3 their emotional representations score would equal 4 (i.e. 16/4). Thus, all available information from participants could be used.
Author Manuscript
Caregiver Questionnaire—The Caregiver Questionnaire collected the following caregiver variables: gender (female or male); age: 18–25 years vs. 26 years and older; race/ ethnicity: Black, White, Other (including Asian, multiracial or Hispanic individuals); marital status: single (including divorced) vs. married (including common law and separated); education: high school diploma/GED or less vs. greater than high school diploma/GED; and employment status: employed vs. not employed. The following variables were collected for each caregiver’s child: age: screening question to determine caregivers’ study eligibility, continuous variable from one to five years; preventive dental visits: at least one preventive dental visit in the past 12 months (including check-ups, dental cleanings, fluoride application) vs. none; dental coverage during the last month (yes or no); and type of dental insurance during the last month: Medicaid, private/employer, don’t know type of coverage, none. Data analysis
Author Manuscript
Analyses were performed with Stata/IC version 13.1 (StataCorp, 2013, College Station, Texas) and SPSS Statistics version 22.0 (IBM Corp., 2013, Armonk, New York). Sociodemographic and clinical characteristics for caregivers and their children were summarized using descriptive statistics (frequencies and means). Bivariate analysis of cases and controls proceeded with Pearson chi-square tests for categorical (sociodemographic and clinical) and independent samples t-tests for continuous variables (i.e. child age, dmft, IPQRD construct-specific summary scores). The IPQ-RD cause sub-items were first examined in an exploratory factor analysis (EFA), consistent with psychometric evaluations of other modified IPQ-R29–30. It is recommended that the cause construct be tested separately because its items are designed to be specific to the illness, making its factor structure different from that of the other constructs in the instrument16. Principal components analyses (PCA) was used as the method for factor extraction. The objective was to identify salient factors that would explain a significant
Pediatr Dent. Author manuscript; available in PMC 2017 April 15.
Slusar and Nelson
Page 5
Author Manuscript
proportion of the variance among the cause items and determine the grouping of items into factors. To determine the number of factors extracted, factors with an Eigenvalue >1 (Kaiser criterion) and a scree test (graphical representation of the Eigenvalues) were considered. Factors were rotated using an oblique oblimin method. An oblique rotation was chosen because it allows correlation between factors and is consistent with psychometric evaluations of the IPQ-R modified for other illnesses19–20, 31. Items with factor loadings > greater than 0.4 were interpreted as representing a particular factor, while items with low factor loadings were removed from subsequent analyses.
Author Manuscript
In the EFA of the 11 cause items, the Kaiser criterion and scree test suggested that three factors be extracted. The rotated three-factor solution explained 66.6 percent of the variance among the cause items. The factors were labeled psychological causes, which accounted for the largest proportion of the variance (Eigenvalue=4.46; variance explained=40.5 percent), risk factors (Eigenvalue=1.59; variance explained=14.4 percent), and biological causes (Eigenvalue=1.58; variance explained=14.3 percent). The following are the items (with factor loadings) representing each factor: psychological causes: “My negative thoughts” (0.462), “Family problems or worries” (0.478), and “My feelings (feeling down, anxious)” (0.476); risk factors: “Diet or eating habits” (0.629), “Poor dental care” (0.609), and “Something I did as a parent” (0.421); biological causes: “A germ or virus” (−0.494) and “Cavities run in my family” (0.761). Three items with low factor loadings (
Pediatr Dent. Author manuscript; available in PMC 2017 April 15. Published in final edited form as: Pediatr Dent. 2016 October 15; 38(5): 425–431.
Caregiver Illness Perception of Their Child’s Early Childhood Caries: A Case-Control Study Mary Beth Slusar, PhD and Research Associate, Community Dentistry, Case Western Reserve University School of Dental Medicine, 10900 Euclid Ave., Cleveland, OH 44106-4905, Telephone: 216-368-2833, Fax: 216-368-1298
Author Manuscript
Suchitra Nelson, PhD Professor, Community Dentistry, Case Western Reserve University School of Dental Medicine, 10900 Euclid Ave., Cleveland, OH 44106-4905, Telephone: 216-368-3469 Fax: 216-368-1298
Abstract Purpose—This case-control study evaluated the association between parent/caregivers’ illness perception and early childhood caries (ECC).
Author Manuscript
Methods—Parent/caregivers of children less than six years old were recruited at the dental clinic of an urban children’s hospital (June 2013-September 2015). Cases were caregivers of children with ECC; controls were caregivers of children without ECC. Caregivers completed the Illness Perception Questionnaire-Revised for Dental (IPQ-RD) assessing cognitive (identity, consequences, control, timeline, illness coherence, cause) and emotional representations of dental caries. Twelve IPQ-RD construct-specific summary scores were calculated; higher scores represented less accurate perception. Logistic regression models examined the relationship between IPQ-RD constructs and ECC. Results—The sample included a total of 165 parent/caregivers: 54 (33 percent) of children without ECC; 111 (67 percent) of children with ECC. Two of twelve constructs were related to ECC status. Controlling for caregiver age, education, race/ethnicity and child age, caregivers of children with ECC had less accurate perception of the consequences of dental caries (OR=2.24; 95% CI: 1.07–4.69) and more accurate perception of the controllability of caries (OR=0.29; 95% CI: 0.11–0.76), compared to caregivers of children without ECC. Conclusion—Our results suggest that clinicians should emphasize the consequences and controllability of ECC to help caregivers self-manage their child’s oral health.
Author Manuscript
Keywords Dental Caries; Caregivers; Perception
INTRODUCTION Recent national estimates indicate that early childhood caries (ECC) remains a persistent problem in the U.S. with prevalence at 23 percent and untreated caries at 10 percent among two to five year olds1. Poor and minority children are disproportionately more likely to have untreated tooth decay, or unfilled cavities1. While 45 percent of all children visited the
Slusar and Nelson
Page 2
Author Manuscript
dentist in 20112, median dental utilization for Medicaid-enrolled children was only 33 percent3. Inaccurate beliefs or lack of knowledge about their child’s oral health (e.g. importance of primary teeth, tooth brushing) and the effectiveness of preventive care (e.g. timing of first dental visit) have been identified as caregiver barriers to promoting healthy oral hygiene practices in their child or seeking dental care for their child4–11 which subsequently can lead to ECC12–15.
Author Manuscript
The Common Sense Model of Self-Regulation (CSM), a useful but underutilized framework, posits that a patient’s (or their caregiver’s) beliefs about their illness and its treatment along with their emotional response affect health outcomes, often through coping strategies16–17. To self-manage their chronic illness, patients (or caregivers) base their illness perception on various sources of information: from a health care provider or relative, cultural knowledge of the illness, and illness threat from past and current experiences with the disease18. The Revised Illness Perception Questionnaire (IPQ-R)16 has been modified for various medical19–20 and psychological21 conditions. But, little attention has been paid to the illness perceptions of the individuals who care for them (i.e. spouses, parents, relatives) or to consideration of dental conditions as chronic illnesses. Dental caries is similar to other chronic conditions in children in that it requires adequate self-management strategies by their parent/caregiver. The Illness Perception Questionnaire-Revised for Dental (IPQ-RD)22 is a newly adapted version of the IPQ-R, modeled after versions used in medicine23.
Author Manuscript Author Manuscript
Incorporating caregivers’ cognitive and emotional representations of their child’s dental caries, the IPQ-RD improves upon existing caregiver oral health measures, e.g. oral health knowledge and attitudes and OHRQoL, that use health behavior theories (e.g. social cognitive theory, health belief model). While oral health knowledge and attitudes measure caregivers’ awareness of facts24–25, they do not assess how those facts are processed. OHRQoL measures, such as the Early Childhood Oral Health Impact Scale (ECOHIS)26 and Pediatric Oral Health-Related Quality of Life (POQL) instrument27, are caregivers’ assessment of the consequences of dental caries and treatments on their child and family, but with a narrow focus on a single dimension. By incorporating multiple cognitive dimensions with emotional processes, the IPQ-RD provides a more complete and dynamic measure of caregivers’ understanding of their child’s dental caries to influence coping and health outcomes. Recently the CSM framework has been used to develop a new theory-based referral approach to improve children’s dental access by addressing caregiver misperception regarding primary teeth and the chronicity of caries28. Except for this study demonstrating the clinical utility of the CSM framework 28, little work has been done to understand differences in the perception of caregivers whose children do and do not have dental caries. Without such empiric data, behavioral interventions to address this misperception will be difficult. Therefore, the aims of this study were to: (1) examine the factor structure of the IPQ-RD “cause” dimension to identify salient cause factors to be included in aim 2; (2) compare the illness perception (cognitive: identity, consequences, cause, control, timeline, illness coherence; and emotional representations) of parent/caregivers of children less than six years old with and without ECC. We hypothesized that children with ECC will have caregivers
Pediatr Dent. Author manuscript; available in PMC 2017 April 15.
Slusar and Nelson
Page 3
Author Manuscript
with less accurate illness perception about dental caries compared to children without ECC, after controlling for relevant covariates.
METHODS Study design and participants
Author Manuscript
A case-control study design was used. Parent/caregivers of children under six years were recruited from the dental clinic at an urban children’s hospital in Cleveland, Ohio from June 2013 to September 2015. Out of 219 caregivers who were approached in the waiting room, 83 percent consented to participate in the study, and 165 caregivers were enrolled (i.e. 16 were excluded due to eligibility criteria or missing data). Caregivers were not asked at the time of recruitment if their child had dental caries. They were enrolled before their child saw the dentist and given two questionnaires to complete: IPQ-RD and Caregiver Questionnaire. Once data was abstracted from their child’s dental chart (i.e. after their child’s dental appointment), caregivers were assigned accordingly to the case or control group. Cases were caregivers of children with ECC (total number of decayed, missing, filled primary teeth: dmft equal to or greater than one), and controls were caregivers of children without ECC (dmft equal to zero). Measurement of early childhood caries adhered to the American Academy of Pediatric Dentistry (AAPD) guidelines. The study was approved by the University Hospitals Case Medical Center Institutional Review Board (Cleveland, Ohio), and informed consent was obtained from caregivers (parent or legal guardian). Data collection and measures
Author Manuscript
Data abstraction—Child data—total number of teeth and dmft—were abstracted from dental charts. Clinical examinations were performed by residents or faculty in pediatric dentistry.
Author Manuscript
Illness Perception Question-Revised for Dental (IPQ-RD)—The IPQ-RD is comprised of 10 CSM constructs (33 items) assessing caregivers’ cognitive and emotional representations of their child’s dental caries. The psychometric properties of the IPQ-RD have been tested and validated22 without the inclusion of the cause construct as recommended previously16. The cognitive dimensions, or constructs, include the following: identity [two items]: caregiver’s perception of the intensity of symptoms associated with their child’s dental caries (e.g. “Cavities is an illness with many symptoms.”); consequences-child [seven items]: beliefs about the serious consequences of caries on their child’s daily activities (e.g. “Cavities in my child has a big effect on his/her school work.”); consequences-caregiver [five items]: beliefs about the serious consequences of their child’s caries on their own life (e.g. “Cavities in my child has a big effect on how others see me.”); control-child [four items]: beliefs about whether their child’s caries and its symptoms can be prevented, improved, and/or kept under control by their child’s actions (e.g. “What my child does decides if his/her cavities get better or worse.”); control-caregiver [four items]: beliefs about whether their child’s caries can be prevented, improved, and/or kept under control by their own actions (e.g. “There is a lot I can do to prevent cavities in my child.”); timelinechronic [two items]: beliefs about the chronicity and duration of their child’s caries (e.g. “Cavities in my child are likely to be long-lasting rather than short-term.”); timeline-cyclical
Pediatr Dent. Author manuscript; available in PMC 2017 April 15.
Slusar and Nelson
Page 4
Author Manuscript
[two items]: beliefs about the predictability of their child’s caries and its symptoms (e.g. “There will be times when my child’s cavity symptoms get worse and times when they get better.”); illness coherence [two items]: whether the caregiver has a clear understanding of their child’s caries and its symptoms (e.g. “My child’s cavity symptoms are not confusing to me.”); and cause [with 11 sub-items]: caregiver’s perception of the causes of their child’s caries (e.g. “Stress or worry caused my child’s cavities.”). Emotional representations [four items] is an assessment of the caregiver’s emotional response to their child’s dental caries (e.g. “Seeing my child with cavities makes me feel angry.”).
Author Manuscript
Each item was scored on a 5-point Likert scale (1=strongly agree, 2=agree, 3=neither agree nor disagree, 4=disagree, 5=strongly disagree) with a higher score representing less accurate perception. IPQ-RD construct-specific summary scores were calculated from the mean rather than the sum of items in each construct for each caregiver. For example, if the values of a caregiver’s responses for the four emotional representations items were 4, 5, 4, and 3 their emotional representations score would equal 4 (i.e. 16/4). Thus, all available information from participants could be used.
Author Manuscript
Caregiver Questionnaire—The Caregiver Questionnaire collected the following caregiver variables: gender (female or male); age: 18–25 years vs. 26 years and older; race/ ethnicity: Black, White, Other (including Asian, multiracial or Hispanic individuals); marital status: single (including divorced) vs. married (including common law and separated); education: high school diploma/GED or less vs. greater than high school diploma/GED; and employment status: employed vs. not employed. The following variables were collected for each caregiver’s child: age: screening question to determine caregivers’ study eligibility, continuous variable from one to five years; preventive dental visits: at least one preventive dental visit in the past 12 months (including check-ups, dental cleanings, fluoride application) vs. none; dental coverage during the last month (yes or no); and type of dental insurance during the last month: Medicaid, private/employer, don’t know type of coverage, none. Data analysis
Author Manuscript
Analyses were performed with Stata/IC version 13.1 (StataCorp, 2013, College Station, Texas) and SPSS Statistics version 22.0 (IBM Corp., 2013, Armonk, New York). Sociodemographic and clinical characteristics for caregivers and their children were summarized using descriptive statistics (frequencies and means). Bivariate analysis of cases and controls proceeded with Pearson chi-square tests for categorical (sociodemographic and clinical) and independent samples t-tests for continuous variables (i.e. child age, dmft, IPQRD construct-specific summary scores). The IPQ-RD cause sub-items were first examined in an exploratory factor analysis (EFA), consistent with psychometric evaluations of other modified IPQ-R29–30. It is recommended that the cause construct be tested separately because its items are designed to be specific to the illness, making its factor structure different from that of the other constructs in the instrument16. Principal components analyses (PCA) was used as the method for factor extraction. The objective was to identify salient factors that would explain a significant
Pediatr Dent. Author manuscript; available in PMC 2017 April 15.
Slusar and Nelson
Page 5
Author Manuscript
proportion of the variance among the cause items and determine the grouping of items into factors. To determine the number of factors extracted, factors with an Eigenvalue >1 (Kaiser criterion) and a scree test (graphical representation of the Eigenvalues) were considered. Factors were rotated using an oblique oblimin method. An oblique rotation was chosen because it allows correlation between factors and is consistent with psychometric evaluations of the IPQ-R modified for other illnesses19–20, 31. Items with factor loadings > greater than 0.4 were interpreted as representing a particular factor, while items with low factor loadings were removed from subsequent analyses.
Author Manuscript
In the EFA of the 11 cause items, the Kaiser criterion and scree test suggested that three factors be extracted. The rotated three-factor solution explained 66.6 percent of the variance among the cause items. The factors were labeled psychological causes, which accounted for the largest proportion of the variance (Eigenvalue=4.46; variance explained=40.5 percent), risk factors (Eigenvalue=1.59; variance explained=14.4 percent), and biological causes (Eigenvalue=1.58; variance explained=14.3 percent). The following are the items (with factor loadings) representing each factor: psychological causes: “My negative thoughts” (0.462), “Family problems or worries” (0.478), and “My feelings (feeling down, anxious)” (0.476); risk factors: “Diet or eating habits” (0.629), “Poor dental care” (0.609), and “Something I did as a parent” (0.421); biological causes: “A germ or virus” (−0.494) and “Cavities run in my family” (0.761). Three items with low factor loadings (
