La teoría del capital humano

In addition to generating revealing data about the nature of mother’s cognitions about dyadic toothbrushing more generally, the interviews also generated more specific data about the nature of dyadic holding and use of the toothbrush during toothbrushing. One of the perceived barriers to mothers having principal control of holding and using the toothbrush during dyadic toothbrushing was that mothers reported a number of difficult infant behaviours during toothbrushing. These ranged from general non- compliancy such as tantrums to more specific behaviours, such as refusal to open their mouth and trying to man-handle the toothbrush. These kinds of difficult, non-compliant behaviours are commonplace during the infant years (aged 2-3 years) and were reported in the Amin & Harrison (2009) and Heubner & Riedy (2010) dental health interview studies.

A recent study reported rates of difficult, non-compliant behaviours in approximately 10% of UK children without developmental delay (Emerson and Einfeld, 2010). These behavioural difficulties are also associated with caregiver stress (Williford et al., 2007), although the research indicates that this relationship may be bi-directional. It would appear that although difficult infant behaviours are understandably stressful for caregivers to have to cope with on a daily basis (Williford et al., 2007) caregiver stress may actually contribute to the development of these behaviours (Whittaker et al.,

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2011). Caregiver stress may lead to early non-compliant child behaviours because stressed caregivers, especially those living in socially deprived environments, have been found to engage in less consistent, more punitive parenting behaviours (Kohen et al., 2008), i.e. do not engage in positive parenting practices. Positive parenting practices have consistently been demonstrated to protect children from the development of non- compliant and other difficult behaviours such as oppositional-defiant and externalising behaviours (Dishion et al., 2008).

Caregiver stress, less positive parenting and therefore increased child behavioural difficulties have been found to be more prevalent in lower SES families (Cote et al., 2006). This may go some way to explaining the high rates of ECC in socially deprived areas. More families in low SES areas may be experiencing behavioural difficulties with their infant-aged children being non-compliant than families in higher SES areas. However, due to their increased stress levels (due to increased financial difficulties and other risk factors), they may feel less able to engage in positive parenting practices to overcome their infants difficult behaviours (which require time and patience; resources these caregivers may lack). Therefore, it would make sense that families in lower SES areas would have more problems overcoming these difficult child behaviours whilst attempting to engage in dyadic toothbrushing, and concede to infants attempts to take principal control of holding and using the toothbrush. This may provide one possible explanation for the higher rates of dental caries seen in children living in socially deprived environments, as infants may not be able to effectively clean their teeth to an adequate level of hygiene to prevent caries.

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Despite the non-compliant behaviours reported by the majority of mothers, dyadic toothbrushing did seem to be in place with all the families in the study, even if they did not always align with the dental expert guidelines. Mothers had managed to overcome the impact of non-compliance through the use of a number of parenting behaviours and strategies. Providing education on these strategies would form an invaluable component of cognitive-behavioural interventions to help caregivers establish dyadic toothbrushing with their infants. The specific strategies used by mothers included a number of positive parenting strategies such as turning toothbrushing into a fun game, for example by using songs and games. This again concurs with the wealth of literature in the importance of play for a number of child developmental outcomes and for learning (Ginsburg et al., 2007; Vygotsky, 1978b).

In addition to making toothbrushing more fun and engaging for infants, mothers reported using other ‘positive parenting’ techniques. In doing this, mothers reported that they provided infants with the opportunity to become an active agent in the activity, allowing them to have some control over proceedings and engage in brushing their teeth themselves. Although this technique does not strictly conform to the dental expert guidelines, mothers reported that they found this parenting strategy to be helpful when trying to overcome child resistance to toothbrushing. It would appear from the data collected in this study that mothers perceived that infants responded more positively to toothbrushing when it is less of a ‘procedure’ that is carried out upon them by an adult, and more of an activity that they can claim some ownership and self- control of. This was also something that was briefly alluded to in the findings from the Heubner & Riedy (2010) study.

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A further finding from the present study that supports the idea that infants wanted to have some ownership and autonomy during dyadic toothbrushing, was that mothers revealed in many cases that infants wanted to try to brush their teeth themselves. This may be a further important finding that may contribute to explaining the nature of dyadic toothbrush use during infant-hood. It may also, in part, also explain why studies have found that infants are engaging in more autonomous toothbrush use, and having more control of holding and using the toothbrush, than the dental expert guidelines recommend (BDHF, 2008; Huebner and Riedy, 2010; Zeedyk et al., 2005).

The finding regarding infant drive for autonomy in toothbrushing also concurs with Erikson’s classical theory of human development (Erikson, 1968) and newer revisions of the theory (Newman and Newman, 2008). These theories state that around the age of 18-months, children reach a stage of development characterised by the need for autonomy versus shame and doubt. In this stage children want to try to do everything for themselves but are scuppered by the restrictions their caregivers put upon them, and the child’s failed attempts to correctly execute particular skills. If they fail to execute these skills successfully it can lead to impaired self-esteem and confidence later on. Caregivers can provide a framework to facilitate the development of skills in their child to satisfy their child’s need for autonomy whilst at the same time providing enough guidance and support to allow successes to be achieved. This process requires patience on the part of caregivers as they guide their child through the process of developing new skills through trial and error. It also requires the caregiver, whilst allowing their child to fulfil their need for autonomy via experimentation, to also curtail

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this need for autonomy where appropriate in order to improve the chances their child develops socially appropriate behaviours.

This requirement of caregivers, to curtail where appropriate an infant’s drive for autonomy, is perhaps an important consideration for dyadic toothbrushing during this period of development. In the present study only a few of the mothers interviewed made comments that indicated that they were aware that they should curtail the infants drive to hold and use their toothbrush themselves and engage in self- toothbrushing. Reasons mothers gave for wishing to curtail their infants drive for autonomy during toothbrushing, were largely related to their concern that their infant was not able yet to brush their own teeth to an adequate level of hygiene. Perhaps the reason some infants are being found to have more autonomous control of holding and using the toothbrush during toothbrushing than the dental expert guidelines recommend is that some caregivers do not understand the importance of caregiver conducted tootbrushing of infant teeth. Or, they may not feel able to overcome their infant’s drive for autonomy in toothbrush use during toothbrushing.