Comparison of Chairside Cooperative Ability with Social Quotient of Mentally Challenged Children
ntroduction Developing a positive attitude toward dental care in children and involving them in a positive way during dental visits is the cornerstone of pediatric dentistry practices. The field of dentistry, being an interactive one, has increased its focus on the relationship between patients and dental professionals. Despite technological advances in dentistry today, pediatric dentists may still find it challenging to perform dental procedures on children, as their levels of compliance vary. The child's cooperation and compliance with the dental procedure often determine the success of the treatment. The child's emotional and behavioral response in the dental chair is a matter of concern to pediatric dental practitioners. The behavior of the child in the dental setting may be affected by their anxiety toward the dental procedure. Pediatric dentists must therefore be able to examine and evaluate the child's psychological, emotional, and behavioral responses, which in turn can help modify treatment strategies to reduce dental fear and anxiety. Pediatric dental professionals should comply with two main goals: delivering effective and efficient dental care to children and motivating them to have a positive attitude. Children's positive attitude toward dental treatment is strongly linked to successful treatment. Several rating scales have been developed for evaluating a child's behavior during dental visits, such as the Frankl rating scale, Venham behavior rating scale, Houpt clinical rating scale, Wong–Baker facial scale, and visual analog scale. Children's reactions to dentistry, including their interest in and acceptance of dental treatment, are frequently recorded using these scales. The Frankl behavior rating scale (Frankl et al., 1962) is the most commonly used tool for evaluating a child's cooperativeness. In addition, it can be used for children with intellectual disabilities, as the dentist assesses the behavior of children and their cooperation during treatment on a four-point scale ranging from “definitely negative” to “definitely positive.” This is in contrast to other scales that use either pictorial representations or facial images that are assessed directly by the child. Special health needs children are those with disabilities that limit their ability to perform daily activities. The World Health Organization defines disabilities as a broad category encompassing impairments, limitations in activities, and participation restrictions. Mental retardation is defined as a disability that manifests before the age of 18 years and is demonstrated by substantial limitations in intellectual functioning and adaptive behavior, as evidenced by conceptual, social, and practical adaptive skills. Special health care conditions like cerebral palsy, Down syndrome, autism, Treacher Collins syndrome, Moebius syndrome, Van der Woude syndrome, fragile X syndrome, etc., are usually associated with intellectual disability. Social intelligence (SI) is a person's ability for effective interpersonal communication. It is a skill that encompasses self-awareness, situation awareness, and comprehending social dynamics. Low SI and poor interpersonal communication are characteristics of underdeveloped behavior. Social maturity is defined as a person's level of social awareness and skills compared to the norms of a specific age-group. It assesses a person's level of developmental competency, behavior appropriateness, social problem solving, interaction with others, and judgment. The concept of social maturity includes accomplishments in a number of areas, such as responsibility for contributing to the welfare of society, interactivity, independent functioning, and communication. In an earlier study in 1971, it was found that among individuals with mental retardation (MR), the intellectual level varies with the level of social development. The ability to conduct oneself in accordance with social expectations is acquired through social development, which significantly improves one's quality of life. Social quotient is defined as the ratio of social age to chronological age. Similar to an IQ, a social quotient score of 100 implies normal or average performance, while scores below 100 indicate below-average functioning. It serves as an indicator of social maturity and is typically assessed using the Vineland Social Maturity Scale (VSMS). This scale is used to assess social and adaptive functions or social competency. VSMS is the most preferred test to assess the social development of children who are very slow in communicating, adaptive skills, or individuals suspected of intellectual disabilities. It has proven to be an exceptionally valuable tool for assessing the social maturity of children and young adults. In 1965, Dr Malin from the Nagpur Child Guidance Centre modified this scale to suit Indian cultural norms. The use of the Vineland Social Maturity Scale at the Nagpur Child Guidance Centre has confirmed its usefulness with mentally retarded children. Since then, the VSMS scale has been used to assess the SI of mentally retarded children in India. This instrument indicates social deficits and social assets in the growing child in addition to measuring social age and social quotient. An individual's success in all aspects of life can be strongly predicted by social quotient. A child's anxiety in a dental setting has been shown to be more significantly impacted by low SI. Usually, individuals with intellectual disabilities tend to have poorer oral health. Factors such as underlying etiology, poor social development, parental knowledge, and residential arrangements influence the oral health of individuals with MR. Moreover, a low level of SI, fewer adaptive skills, and poor social development may make these children more anxious, and thus they may take a longer time to accept dental treatment. Hence, it is important to assess the relationship between the social quotient and their cooperation with dental treatment among children with mental retardation. If a significant relationship is found, necessary modifications can be made to the dental treatment program. A therapeutic program and social stories appropriate to their social level can be planned to improve the social skills of the child, making dental treatment more acceptable for the children. In this study, we aimed to examine the relationship between the social quotient and behavior, as well as cooperativeness, in a dental setting among children with mental retardation. 

aterials and M ethods A cross-sectional study was conducted to assess the relationship between the chairside cooperative ability and social quotient of 6–12-year-old mentally challenged children. Ethical approval was obtained from the Institutional Human Ethics Committee (Proposal No.: 339/IHEC/May 2021). This study was conducted in an institute for special children after obtaining permission from the relevant authorities. Prior to the study, the legally accepted representative who accompanied the child to the institution was briefed about the details of the study. The caretaker was provided with a participant information sheet and given an opportunity to ask questions. The investigator addressed all their doubts, and written informed consent was obtained. Inclusion Criteria Children with mental retardation who sought rehabilitation services at the Institute for Special Children. Children whose parents had given permission for them to take part in the study. Exclusion Criteria Children with hearing impairment, visual abnormalities, and physical handicaps. Medically compromised children. The study proforma consisted of three sections. The first section includes a study participant's demographic profile and medical conditions. All clinical examinations were conducted by a single trained and calibrated examiner. Medical information was obtained from these children's individual files at the institute. The second part involved the assessment of the child's social quotient using the Modified Vineland Social Maturity Scale. In the third part, the Frankl behavior rating scale was used to assess the cooperative abilities of study participants during their dental examination. Vineland Social Maturity Scale is a 117-item questionnaire designed to measure the social quotient through interviews with parents or other primary caregivers and is frequently used for individuals from birth to 30 years of age. It includes everyday living skills (such as eating, dressing, and general self-care); communication skills (speaking, listening, and writing); fine and gross motor skills, including locomotion; occupational skills; socialization skills (interpersonal relationships and coping mechanisms); and self-direction. In 1965, Rev. Fr Dr A J Malin of the Nagpur Child Guidance Centre adapted this scale to Indian cultural contexts. He modified it into 89 items consisting of some personal and social skills. In this study, social quotient was assessed using this Indian adaptation of the modified VSMS. This scale, intended for use with individuals from birth to 15 years of age, consists of 89 questions that assess social maturity, with each question having three response options: yes, sometimes, and no. A score of one is given for each “yes” response, a score of 0.5 for “sometimes,” and a score of 0 for “no.” The maximum possible score is 89. Social quotient is calculated using the social age, which is determined by converting the Bharat Raj conversion score of raw scores into an age-equivalent score (expressed as social age), and a social quotient is obtained using social age. Based on the social quotient score, children were categorized into mild, moderate, severe, and profound retardation. After assessing the social quotient of the mentally retarded children, the chairside cooperative ability for intraoral examination was assessed using the Frankl behavior rating scale. This scale has four options: definitely negative, negative, positive, and definitely positive. Among the four ratings, the patient's behavior rating was noted based on the patient's cooperation level. The obtained data was recorded and statistically analyzed. 

Children with mental retardation who sought rehabilitation services at the Institute for Special Children. Children whose parents had given permission for them to take part in the study. 

Children with hearing impairment, visual abnormalities, and physical handicaps. Medically compromised children. The study proforma consisted of three sections. The first section includes a study participant's demographic profile and medical conditions. All clinical examinations were conducted by a single trained and calibrated examiner. Medical information was obtained from these children's individual files at the institute. The second part involved the assessment of the child's social quotient using the Modified Vineland Social Maturity Scale. In the third part, the Frankl behavior rating scale was used to assess the cooperative abilities of study participants during their dental examination. Vineland Social Maturity Scale is a 117-item questionnaire designed to measure the social quotient through interviews with parents or other primary caregivers and is frequently used for individuals from birth to 30 years of age. It includes everyday living skills (such as eating, dressing, and general self-care); communication skills (speaking, listening, and writing); fine and gross motor skills, including locomotion; occupational skills; socialization skills (interpersonal relationships and coping mechanisms); and self-direction. In 1965, Rev. Fr Dr A J Malin of the Nagpur Child Guidance Centre adapted this scale to Indian cultural contexts. He modified it into 89 items consisting of some personal and social skills. In this study, social quotient was assessed using this Indian adaptation of the modified VSMS. This scale, intended for use with individuals from birth to 15 years of age, consists of 89 questions that assess social maturity, with each question having three response options: yes, sometimes, and no. A score of one is given for each “yes” response, a score of 0.5 for “sometimes,” and a score of 0 for “no.” The maximum possible score is 89. Social quotient is calculated using the social age, which is determined by converting the Bharat Raj conversion score of raw scores into an age-equivalent score (expressed as social age), and a social quotient is obtained using social age. Based on the social quotient score, children were categorized into mild, moderate, severe, and profound retardation. After assessing the social quotient of the mentally retarded children, the chairside cooperative ability for intraoral examination was assessed using the Frankl behavior rating scale. This scale has four options: definitely negative, negative, positive, and definitely positive. Among the four ratings, the patient's behavior rating was noted based on the patient's cooperation level. The obtained data was recorded and statistically analyzed. 

esults The present study was conducted to find the association between the chairside cooperative ability and social quotient of mentally retarded children using the Frankl behavior rating scale and the Modified Vineland Social Maturity Scale. The study comprised 166 children who satisfied the inclusion criteria. The average age of the study population is 8.9 years, consisting of 84 boys (50.6%) and 82 girls (49.4%). represents the distribution of the study population according to the severity of retardation based on social quotient. Thirty-three point seven percent, 18.7%, 34.9%, and 12.7% of the study population had mild, moderate, severe, or profound retardation, respectively ( ). represents the distribution of the study population according to the cooperative ability based on the Frankl behavior rating scale. Thirty-four point three percent, 31.9%, 20.5%, and 13.3% of the study population had definitely negative, negative, positive, and definitely positive Frankl behavior rating scores, respectively ( ). compares the study population's social quotient with chairside cooperation ability. Fifty-six, 31, 58, and 21 children in the study population were mildly, moderately, severely, or profoundly retarded based on their social quotient. Among the 56 children at the mildly retarded level, 21.4% exhibited uncooperative behavior (Frankl negative or definitely negative) and the remaining 78.6% exhibited cooperative behavior (Frankl positive or definitely positive). In moderately retarded children, uncooperative behavior was displayed by 71% and cooperative behavior by 29%, respectively. Among severely retarded children, 94.8% exhibited uncooperative behavior and 5.2% showed cooperative behavior. In the children with profound retardation, 100% showed uncooperative behavior, and no cooperative behavior was exhibited ( ). The Chi-squared test found a statistically significant association between social quotient and Frankl behavior of mentally retarded children ( p = 0.000). represents the distribution of children aged 6–9 based on social quotient and Frankl behavior rating scale. Among 166 children, 98 (59%) were between the ages of 6 and 9. In the present study, 76% of mildly retarded, 23.6% of moderately retarded, and 7.2% of severely retarded children reported cooperative behavior. Profoundly retarded children did not exhibit cooperative behavior. represents the distribution of children aged 10–12 years according to social quotient and Frankl behavior rating scale. In this study, 68 (41%) children were between the ages of 10 and 12. Eighty point six percent of mildly retarded and 35.7% of moderately retarded children reported cooperative behavior. Severely and profoundly retarded children did not exhibit cooperative behavior. presents an age-wise comparison of Frankl behavior among study participants. Twenty-six point five percent of children aged 6 to 9 reported cooperative behavior, compared to 44.1% of those aged 10–12. Conversely, 73.5% of the younger group and 55.9% of the older group exhibited uncooperative behavior ( ). Using the Chi-squared test, a statistically significant difference was observed between the two age-groups ( p = 0.016). shows the distribution of male children according to social quotient and Frankl behavior rating. Among the study population, 84 (50.6%) were boys. In the present study, 81.8% of mildly retarded, 25% of moderately retarded, and 3.7% of severely retarded children reported cooperative behavior. Profoundly retarded children did not exhibit cooperative behavior. shows the distribution of female children according to social quotient and Frankl behavior rating. Eighty-two (49.4%) were girls among the study population. In the present study, 73.9% of mildly retarded, 31.6% of moderately retarded, and 6.5% of severely retarded children reported cooperative behavior. Profoundly retarded children did not exhibit cooperative behavior. shows the gender-wise comparison of Frankl behavior among the study population. In this study, 36.9% of boys and 30.5% of girls reported cooperative behavior, while 63.1% of boys and 69.5% of girls displayed uncooperative behavior ( ). The Chi-squared test revealed that there was no statistically significant gender difference ( p = 0.252). shows the distribution of children with cerebral palsy according to social quotient and Frankl behavior. Thirty-eight point nine percent, 75, 92.3, and 100% of mildly, moderately, severely, and profoundly retarded children exhibited uncooperative behavior. shows the distribution of children with autism spectrum disorder according to social quotient and Frankl behavior rating. Forty-four point five percent, eighty-one point nine percent, one hundred percent, and one hundred percent of mild, moderate, severe, and profound retarded children exhibited uncooperative behavior. shows the distribution of Down's syndrome children according to social quotient and Frankl behavior rating. 3.4, 25, 80, and 100% of mild, moderate, severe, and profound retarded children exhibited uncooperative behavior. shows the distribution of social quotient level across mental retardation categories (ASD, CP, DS). In this study, the majority of children with Down's syndrome (64.4%) belong to the mildly retarded category. On the other hand, most of the children with autism spectrum disorder fell into the severe (50.7%) and profound (20.3%) retarded categories. Children with cerebral palsy were found to be prevalent in mild (34.6%) and moderate (30.8%) social quotient levels ( ). shows the distribution of Frankl behavior rating among mental retardation categories. In this study, the majority of children with ASD (89.9%) and CP (69.2%) were reported to have uncooperative behavior. On the other hand, only 26.6% of children with Down's syndrome reported uncooperative behavior ( ). 

iscussion Children often find it challenging to comply during dental treatment due to their limited communication skills, emotional immaturity, inadequate socialization, and language skills. These conditions may result in uncooperative behavior during dental appointments. In general, dental health is essential for all children, and it is particularly crucial for children with disabilities, who are highly prone to dental problems. The oral health of children with disabilities is often neglected due to their inadequate mental development and restricted access to dental care. Earlier studies suggest that children with disabilities between the ages of 6 and 12 years have poor oral health and a higher proportion of dental treatment needs. Intellectually disabled is the other term used to refer to mental retardation. The characteristic features of intellectual disability include significantly limited intellectual abilities, considerable impairments in adaptive behavior, and the onset of these symptoms before adulthood. Furthermore, these children may also have difficulty socializing. Individuals with intellectual disabilities have a defining feature of poor social skills, which often results in challenging behaviors. Academic, adaptive, and psychological functioning are all significantly influenced by such deficiencies. They find it challenging to follow instructions, engage in social interaction, make decisions, and demonstrate flexibility. Social skill is a complex entity that is related to human functioning in society. This can be acquired if individuals have fundamental skills such as interpersonal skills, emotional competence, and SI. An individual can develop healthy interpersonal relationships through the use of SI. SI is essential for resolving social issues and supporting various social activities. Inadequate SI among children with intellectual impairment makes them more anxious than typically developing children. Due to their difficulty interacting with others, they may be uncooperative in dental settings. The present cross-sectional study was conducted to assess the relationship between the chairside cooperative ability and social quotient of mentally retarded children, using the Frankl behavior rating scale and the modified VSMS scale, respectively. Subjects for the present study included 166 children with mental retardation between the ages of 6 and 12, who also had comorbid conditions such as Down's syndrome (DS), autism spectrum disorder (ASD), and cerebral palsy (CP). The majority of the participants (66.2%) in the present study exhibited uncooperative behavior in a dental environment. Similar findings were observed in an earlier investigation on children with ASD, where 55.2% of the patients were uncooperative for dental treatment. The study also reported that 77% of the children with autism were frightened and uncooperative during their first dental visit to the dentist. In the present study, mildly retarded children with higher social quotient exhibited better cooperative behavior compared to children with moderate, severe, and profound retardation. Therefore, as the level of social quotient increased, the children's cooperative behavior increased correspondingly. There have been no studies correlating the social quotient with dental behavior to date. However, a few earlier studies have examined the relationship between intellectual quotient and dental behavior. An earlier study by Toledano et al. 1995 reported that intellectual quotient is significantly correlated with anxiety at the first dental visit. Similarly, Khosrozadeh et al. 2022 reported a positive correlation between cooperation level in dental settings and IQ. Kumar et al. 2009 reported that social development decreases as the severity of retardation increases. On the contrary, Shetty et al. 2018 found no correlation between IQ and Frankl behavior rating in hearing and speech impaired children. This could be attributed to the fact that children with speech and hearing impairment do not exhibit intellectual disability. In this study, uncooperative behavior (73.5%) was found to be higher among 6–9-year-old children compared to 10–12-year-olds (55.9%). This finding aligns with the results of the study reported by Shetty and Hedge 2016 and Lakhani et al. 2017, who reported that negative behavior was noted more often among the younger children. In this study, uncooperative behavior was found to be higher among girls than boys; however, the difference was not statistically significant. Ten Berge et al. 2002, Pandiyan and Hedge 2016, and Toledano et al. 1995 observed a similar trend, where uncooperative behavior was more prevalent among girls compared to boys. This finding may be attributed to the fact that girls and younger children are more fearful compared to boys and older children, and therefore exhibit negative behavior in the dental setting. In this study, the majority of the Down's syndrome children were mildly retarded (64.4%), whereas only 34.6% of children with cerebral palsy and 13% of children with ASD were mildly retarded. These findings imply that the social quotient was higher in Down's syndrome children compared to those with CP and ASD. Earlier studies by Barendse et al. 2018 and Ostensjo et al. 2003 have reported that high-functioning adolescents with ASD and children with CP had social impairments in day-to-day activities. In this study, 89.9% of children with ASD displayed more uncooperative behavior compared to children with CP (69.2%) and DS (26.6%). This finding was in accordance with the previous study by Marshall et al. 2006, who reported that 65% of children with ASD had uncooperative behavior. Similarly, Loo et al. 2008 reported that 55.2% of patients with ASD were uncooperative. The reasons attributed for this uncooperative behavior were language difficulties, sensory stimulating activities, poor adaptive functioning, and possible discomfort. Hence, in addition to social quotient, other factors may also contribute to their uncooperative behavior. In another study, Silva et al. 2020 reported that children with DS had higher uncooperative behavior compared to normal healthy children. The reason attributed for this finding is communication difficulties and poor perception skills. The results of the present study clearly indicate a significant association between children's behavior in the dental setting and social quotient. As the level of social quotient increases, the child's cooperativeness in the dental environment increases. Children with DS had a higher social quotient than children with CP, and ASD children displayed better cooperative behavior in the dental setting. 

onclusion The present study concludes that children with a higher social quotient exhibited better cooperative behavior than children with a lower social quotient. Therefore, social development has a considerable impact on the child's behavior during dental treatment. Children with a higher level of social quotient are more capable of coping with dental treatment. Conversely, those with a lower social quotient may face difficulties, for which pediatric dentists can use appropriate behavior management techniques based on their social development. The study findings suggest that knowledge of the social quotient can help predict the child's cooperation and thus serve to plan the treatment approach. Clinical Significance Social development has a considerable impact on the child's behavior during dental treatment. Children with a higher level of social quotient are more capable of coping with dental treatment. 

Social development has a considerable impact on the child's behavior during dental treatment. Children with a higher level of social quotient are more capable of coping with dental treatment. 

upplementary M aterial The supplementary material is available online on the website of https://www.ijcpd.com/journalDetails/IJCPD 

rcid Senthil Eagappan AR https://orcid.org/0000-0003-2933-6272 Daya Srinivasan https://orcid.org/0000-0001-5453-4380 Lakshmi Priya Mohan https://orcid.org/0000-0001-8588-2994 Balakrishnan Priyanka https://orcid.org/0000-0002-7838-7992 Asvitha B https://orcid.org/0009-0002-1983-1501 Pragadesh Ganesh https://orcid.org/0009-0007-7234-5728 

