Assessment of dental anxiety using the Child Drawing: Hospital scale and oral health-related quality of life in children diagnosed with Familial Mediterranean Fever

1. Introduction

Familial Mediterranean Fever (FMF) is one of the most common autoinflammatory diseases worldwide. It is characterized by recurrent acute attacks lasting approximately 6–72 hours, which resolve spontaneously, and are typically accompanied by fever, peritonitis, pleurisy, pericarditis, arthritis, or erysipelas-like skin rashes [1].

The effects of chronic illnesses on children are not limited to physical symptoms as they also substantially affect psychological well-being, social functioning, and family dynamics [2, 3]. In a study by Gortmaker et al. [4], 10% of adolescents with chronic illness were reported to experience behavioral problems, such as social withdrawal, aggression, and depression, and psychiatric disorders were 1.55 times more common in these individuals than in healthy peers. Children with chronic illnesses and their parents have been reported to show greater depressive and anxiety symptom severity, and such psychosocial burden may directly influence healthcare access, treatment adherence, and the overall quality of clinical experiences [5].

Dental anxiety refers to fear- and anxiety-related responses that an individual develops towards dental procedures, and it is common in childhood [6]. This anxiety towards dental treatment may lead to postponement or even complete avoidance of care, resulting in serious consequences for oral health [7, 8]. Evidence suggests that dental anxiety developed during childhood can persist into adulthood, thereby negatively influencing population-level oral health [9]. Therefore, early identification of dental anxiety in children is important for developing effective management and treatment approaches [10]. Furthermore, dental anxiety has been associated with poorer oral health-related quality of life (OHRQoL) in both pediatric and adult populations [11].

At present, there are various techniques that can be used to assess dental anxiety in children, including behavioral scoring, psychometric measures, physiological indicators, and projective techniques [12]. In projective techniques, the aim is to explore fear and anxiety by asking children to tell stories about purposefully designed pictures or to depict objects or living beings that they perceive as frightening. One such projective method, the Child Drawing: Hospital (CD:H) scale, enables children to express emotional states through drawings and has been used as an alternative approach for assessing dental anxiety [13]. In this method, the child is instructed to draw a picture of a person in a hospital setting, based on which a standardized procedure has been established to support consistent interpretation and scoring of the drawings, and recently, this method has been adopted in dentistry to evaluate dental anxiety [14, 15, 16].

Psychometric tests are among the most commonly used methods for assessing dental anxiety in children because they are easy to administer and standardized; however, the choice of instrument varies by age group. These methods are based on a question-and-answer format and depend on the child’s ability to express themselves verbally [12]. One such instrument is the Dental Anxiety and Fear Scale (IDAF-4C+), developed by Armfield, which has been demonstrated to be a valid and reliable measure [17, 18].

Oral health-related quality of life (OHRQoL) is a multidimensional construct that assesses the impact of an individual’s oral health on their daily life and is considered an integral part of overall health [19]. In children, one of the most commonly used instruments is the Child Oral Health Impact Profile (COHIP), which assesses oral health, functional status, and socio-emotional well-being. The short form (COHIP-SF19) offers practical advantages for clinical and epidemiological research [20].

In this prospective clinical observational study, we aim to compare dental anxiety levels using the CD:H scale, and OHRQoL between children diagnosed with FMF at an early stage and healthy controls.

2. Methods

2.1 Patient selection

This study comprised children aged 8–12 years who presented to the Department of Pedodontics, Faculty of Dentistry, Tokat Gaziosmanpaşa University, between 01 July and 03 October 2025, for routine dental examinations. The study group consisted of children who were being followed with a diagnosis of FMF and who did not have any other systemic disease. The control group consisted of an equal number of systemically healthy children with similar age and gender to the study group, to facilitate balanced group comparisons. Both groups underwent only dental examinations.

The inclusion criteria for both groups were: parents and children who agreed to participate, children aged 8–12 years, and children with no mental or physical disabilities. For the study group, an additional inclusion criterion was that FMF patients were in an attack-free period at the time of evaluation.

The exclusion criteria for both groups consisted: parents and children who provided incomplete or no answers to the questions, children with color blindness, children who were unwilling to draw, and drawings that were not suitable for analysis (i.e., drawings that did not conform to the drawing instructions specified in Section 2.3.2). For the study group, an additional exclusion criterion was children being followed with a diagnosis of FMF who had other systemic diseases.

A total of 100 children were initially recruited for this cross-sectional clinical observational comparison between children with FMF and healthy controls; however, only 74 were included in the final analysis after exclusions (Fig. 1).

Fig. 1.Study flow diagram and patient selection. FMF: Familial Mediterranean Fever.

2.2 Measurements

Their behavior during the dental examination was evaluated using the Frankl Behavior Rating Scale, while anxiety levels were assessed at the end of the examination through drawings interpreted with the CD:H scale. Dental anxiety and fear were measured using the IDAF-4C questionnaire, and oral health-related quality of life was assessed with the COHIP-SF19. The DMFT/dmft indices of all children were recorded. For children diagnosed with FMF, disease severity was determined based on symptoms obtained during anamnesis using the Modified PRAS Severity Score.

2.2.1 Frankl behaviour rating scale

For both the study and healthy groups, the children’s behavior was observed during the examination, and at the end of the examination, each child’s behavioral status was recorded using the Frankl Behavior Rating Scale (definitely negative, negative, positive, or definitely positive) [21].

2.2.2 Child Drawing: Hospital scale

After the examination, children in both the study and healthy groups were asked to draw a picture. Prior to drawing, the examiner instructed them as follows: “I examined your mouth today. Thinking about your experience and what happened during your visit, I would like you to draw a picture of me and you. You can use any of the crayons here. You can start drawing when you’re ready and stop whenever you want. I’m not giving you a specific time. I want you to tell me when you think your drawing is finished.”. The drawings were completed using A4 paper and crayons in eight colors (red, purple, blue, green, yellow, orange, black, and brown). The papers were collected once the drawing was finished (Fig. 2a–d). The drawings were evaluated by researchers (HA and MDD) trained and certified in Child Drawing Analysis. The evaluation process was based on the Child Drawing: Hospital (CD:H) scale, which consists of three parts:

Fig. 2.Examples of children’s drawings. (a) This picture indicates very low stress, and the CD:H score was 43. (b) This picture indicates low stress, and the CD:H score was 73. (c) This picture indicates average stress, and the CD:H score was 93. (d) This picture indicates average stress, and the CD:H score was 118.

- Section A includes 14 items (e.g., location, action, figure size, facial expression, color use, and paper layout), with each item scored on a scale of 1–10.

- Section B includes 8 items regarded as pathological indicators; each indicator is assigned a score of 5 or 10, and a score of 0 is recorded if no symptoms are present.

- Section C is a “gestalt” score reflecting the child’s general anxiety level and is scored on a scale of 1–10.

Children’s anxiety levels were classified according to the total CD:H score as follows: scores ≤43 indicated very low stress, 44–83 low stress, 84–129 moderate stress, 130–167 above-average stress, and ≥168 very high stress [13], and this scale has been previously validated in Turkish settings by Özdemir et al. [14].

2.2.3 IDAF-4C+ dental anxiety scale

The Turkish version of the Dentist Anxiety and Fear Index (IDAF-4C+) was developed by Buldur et al. [17]. Based on the picture drawing, children in both the study and healthy groups were asked to complete the IDAF-4C questionnaire to assess dental anxiety and fear, and their responses to this five-point Likert-type questionnaire ranged from 1 (strongly disagree) to 5 (strongly agree). A mean score of 1.0–1.5 indicated “no or very little dental anxiety”, 1.51–2.5 indicated “low”, 2.51–3.5 indicated “moderate”, and ≥3.5 indicated “high dental anxiety” [18].

2.2.4 Child oral health impact profile-short form 19

The COHIP-SF19 (Child Oral Health Impact Profile-Short Form 19) was administered to children in both the study and healthy groups. This scale consists of three subscales: oral health (5 items), functional health (4 items), and social-emotional well-being (10 items). The children were asked to rate problems related to their teeth, mouth, and face experienced over the past three months on a five-point Likert-type scale ranging from “never” to “almost always”. The last two positively worded items were scored as stated, whereas the first 17 negatively worded items were reverse-scored to calculate the total score (range, 0–76) [20].

2.2.5 Severity of disease

The Modified Pras Disease Severity Score was used to determine FMF severity based on symptoms obtained during medical history collection for children in the study group. In this scoring system, disease severity is determined by the sum of scores assigned to each parameter. Total scores of 3–5 were classified as mild, 6–8 as moderate, and ≥9 as severe (Table 1) [22]. Hospitalization history due to FMF was also recorded for children in the study group.

Table 1.FMF severity scoring systems.

Characteristics	Scores
Age of onset (yr)
	11–20	2
	6–10	3
	<6	4
Numbers of attacks per month
	<1	1
	1–2	2
	>2	3
Arthritis
	Acute	2
	Protracted	3
Erysipelas-like erythema	2
Amyloidosis	3
Dose of colchicine
	Less than appropriate* dose	0
	Appropriate dose	1
	More than appropriate dose	2
Mild disease 3–5; Moderate disease 6–9; Severe disease >9
*Starting colchicine doses for children <5 years 0.5 mg/day; 5–10 years 1.0 mg/day; >10 years 1.5 mg/day.

3. Results

3.8 CD:H scale items data

In Section A of the CD:H scale, Item 1 was found to be the most prominent stress score of 8, as it was reported by most participants. This score was observed in 40.5% of the total study population within the FMF group and 35.1% within the healthy control group. When analyzed within their respective groups, 81.1% of children in the FMF group and 70.3% of children in the healthy control group exhibited this score (Fig. 3). For Item 8, the most frequent stress score was 10 (FMF: 13 children, 17.6%; healthy: 17 children, 23%) (Supplementary material).

Fig. 3.Distribution of CD:H Item A1 scores. FMF: Familial Mediterranean Fever.

In Section B, Item 18 was found to be a predominant stress score of 10, observed in 86.4% of all participants. This distribution corresponded to 40.5% of the total participants belonging to the FMF group and 45.9% belonging to the healthy control group. Looking at the internal distribution of each group, this high stress score was present in 81.1% of children with FMF and 91.9% of healthy controls (Fig. 4a,b) (Supplementary material).

Fig. 4.Distribution of CD:H Item B18 scores. (a) CD:H Item B18 scores in children with FMF. (b) CD:H Item B18 scores in healthy controls.

For Item 19, the most common score was also 10, recorded in 27 children (36.5%) in the FMF group and 30 children (40.5%) in the healthy group. Among children with FMF, score 10 was followed by score 0 (13.5%), whereas in healthy controls, score 10 remained the most frequent (40.5%) with very few scoring 5 or 0 (Fig. 5) (Supplementary material).

Fig. 5.Distribution of CD:H Item B19 scores in children with FMF and healthy controls. FMF: Familial Mediterranean Fever.

For Item 21, a stress score of 10 was most frequently reported by 25 children (33.8%) in both the FMF and healthy groups. Across these items, boys generally exhibited higher stress scores than girls (Supplementary material).

4. Discussion

FMF is a chronic inflammatory disease characterized by recurrent, self-limiting attacks lasting 12–72 hours, separated by symptom-free remission periods [23]. Current literature reports that FMF symptoms mostly begin in childhood, with the most cases presenting their first clinical findings before the age of 20. Although oral colchicine remains the standard long-term therapy, children with FMF have early and repeated contact with healthcare services, which may support treatment adherence, while also influencing the psychosocial burden associated with living with a chronic condition.

Medical doctors, dentists, psychologists, researchers, educators, and parents can use drawing analyses to gain insight into children’s social, emotional, physical, and intellectual development [24]. In this context, the CD:H Scale is a non-threatening, engaging, and easy-to-administer projective measure that allows assessment of the emotional state of school-aged children in relation to their experiences with hospitals and illness [13]. Based on a literature review, we found that no previous study had evaluated stress levels in children with FMF using the CD:H Scale. In our study, higher CD:H anxiety was associated with poorer oral health-related quality of life, and greater FMF severity was linked to less cooperative behavior during dental examination.

Recent studies emphasize the importance of understanding children’s emotional expressions through drawing [24]. In our study, there was no statistically significant difference between healthy children and children with FMF in terms of IDAF-4C and CD:H scores, indicating that dental anxiety and stress levels were similar between the two groups. Consistent with our findings, Altan et al. [25] also reported comparable dental anxiety levels in children with FMF and healthy children based on the Frankl Behavioural Rating Scale and the Children’s Fear Survey Schedule-Dental Subscale. One possible explanation is that FMF is an autoinflammatory disease in which children can usually continue their daily activities outside of attacks, with symptoms occurring episodically. In this respect, it differs from other chronic diseases that require continuous hospitalization or are associated with serious, life-threatening complications (e.g., congenital heart disease, neurological disorders, and hematological diseases) [26]. Children with FMF generally appear physically healthy outside of attacks and can often be managed with home-administered medication (colchicine) [27]. Therefore, their contact with hospitals is typically limited to regular outpatient follow-up. As a result, they may experience fewer stress-inducing exposures such as repeated invasive procedures, prolonged hospital stays, or intensive care needs. It is plausible that this pattern of healthcare exposure may shape children’s perceptions of hospitals and healthcare workers, making these environments feel less threatening and more familiar, and thereby helping them cope more effectively with the hospital experience.

Based on biopsychosocial interpretations, long-term management of a chronic condition can lead to a form of “medical habituation”, as frequent exposure to clinical environments and routine medical care from an early age may contribute to gradual desensitization, thereby reducing the stresses often associated with dental visits. Clinically, these findings suggest that children with FMF may develop a distinct pattern of psychological adaptation based on their chronic disease experience. Thus, rather than assuming increased vulnerability, pediatric dentists should consider that these patients may be more familiar with healthcare settings and procedures. Building on this existing medical familiarity may facilitate a stronger therapeutic alliance and improve cooperation during dental treatment. In addition to chronic illness, traumatic dental injuries, toothache, and limited access to dental care are important risk factors for dental fear and anxiety in children and should be considered [8].

One of the highest scores in our study was obtained for Item A1. Item 1 in Section A of the CD:H scale (“the person’s position”) assesses how children position the person on the paper in their drawings [14]. High scores (8–10) on this item indicate that the figure is placed at the edge of the page, in a corner, or in an isolated area. Such placements are generally interpreted as reflecting anxiety, perceived threat, or social isolation within the hospital or clinic environment [28]. In our study, healthy children had higher CD:H scores than children with FMF; however, this difference was not statistically significant.

In the CD:H scale, Item 18 is scored based on whether any part of the body is depicted as damaged or detached, whereas Item 19 is scored based on omissions such as two hands, two eyes, or a hand or foot in the drawing [13, 14]. In our study, although Section B Items 18 and 19 yielded high scores in both healthy children and those with FMF, the mean scores were higher among healthy participants. High scores on these two items may be regarded as relatively objective indicators of emotional distress reflected in children’s drawings. In this context, the CD:H scale not only captures overall anxiety levels, but also helps to identify the specific characteristics of emotional difficulties expressed through visual representation [29]. When interpreting the CD:H scale, it is essential to recognize that children must have a certain level of drawing ability. Incomplete or exaggerated drawings are often discussed under the hypothesis that “as anxiety increases, children tend to enlarge body parts or omit certain features”. However, some children may not actually be anxious, but may appear so because of limited drawing skills. Therefore, insufficient drawing ability may create the impression of anxiety, underscoring the need for caution when relying solely on projective drawing methods to assess children’s emotional states.

In this study, the CD:H scale was implemented as a structured screening instrument, rather than a definitive diagnostic tool for clinical anxiety. The conceptual framework of our assessment was based on quantifying situational stress using a validated scoring manual, with emphasis on observable drawing features such as figure proportions, color selection, and line quality. By applying this standardized protocol, we aimed to translate qualitative visual expression into quantitative data, thereby reducing the risk of subjective over-interpretation. In this study, we used scales along with drawings to assess clinical anxiety, making the assessment evidence-based. The drawings and scales served as a kind of validation tool in our study. Studies by Özdemir et al. [14] and Guner et al. [15] suggest that the CD:H scale can be used to assess dental anxiety in children.

Our study identified a statistically significant, but weak, negative correlation between Frankl behavior scores and both IDAF-4C and Pras Disease Severity scores. Children with more positive behavior (higher Frankl scores) had lower levels of dental anxiety (higher IDAF-4C scores). These findings indicate that greater disease severity may be associated with reduced cooperation during dental examination. Similarly, Sönmez et al. [30] reported a positive correlation between FMF disease severity and anxiety in children with FMF. Altan et al. [25] also found that higher FMF severity significantly increased dental fear, as measured by the CFSS-DS. Taken together, these findings suggest that children with more severe FMF may experience greater dental anxiety [31]. Therefore, when considering treatment compliance in children with chronic illnesses such as FMF, disease severity, not only the presence of the condition, should be taken into account.

Studies indicate that OHRQoL is often lower in children with chronic diseases. For example, COHIP-SF19 scores have been reported to be significantly lower in children with chronic renal failure than in healthy peers [32]. Similarly, children with type 1 diabetes may show reduced OHRQoL, partly related to oral complications [33]. However, Sönmez et al. [30] reported no difference in quality of life scores between FMF and healthy groups. In our study, although mean COHIP-SF19 scores were lower in the FMF group, the difference was not statistically significant. This suggests that age, gender, FMF severity, and hospitalization history did not have a significant impact on OHRQoL among children with FMF in our sample. Importantly, we identified a significant negative correlation between CD:H and COHIP-SF19 scores, indicating that higher hospital-related anxiety was associated with lower OHRQoL. This finding suggests that anxiety within clinical settings may influence children’s perceptions of their oral health and overall well-being. Therefore, addressing psychological factors in pediatric dental care is important, as reducing anxiety may improve both treatment cooperation and quality of life. In addition, the non-invasive oral administration of colchicine as the mainstay treatment for FMF may help limit potential adverse effects on OHRQoL by reducing the need for intensive medical care [34].

In our study, DMFT/dmft values were similar in children with FMF and healthy controls, suggesting that FMF itself does not appear to increase the risk of dental caries. Younger children exhibited a greater caries burden, which may be related to less established oral hygiene habits, dietary patterns, and the greater need for parental supervision at earlier ages. Moreover, DMFT/dmft was not significantly correlated with dental anxiety (IDAF-4C scores), Child Drawing: Hospital anxiety (CD:H scores), or behavioral cooperation (Frankl scores), implying that caries experience was largely independent of these psychological and behavioral measures in this cohort. Taken together, these findings suggest that although FMF does not appear to exacerbate caries risk, preventive strategies emphasizing oral hygiene and dietary counseling may be particularly important for younger children, regardless of systemic health status.

A strength of this cross-sectional clinical study is that, to the best of our knowledge, it is the first to assess anxiety in children with FMF using the CD:H scale. However, several limitations should be acknowledged, including the relatively small sample size, the single-center setting, and the assessment of FMF patients only during remission. Evaluating children both during attacks and in remission would provide a more comprehensive understanding of the psychological effects of FMF. Future studies with larger samples are also needed to examine the relationship between CD:H scores and gender in greater details.

5. Conclusions

In our study, no significant differences were observed in dental anxiety, stress, behavior, or oral health-related quality of life between children diagnosed with FMF and their healthy peers. This finding suggests that, despite the chronic nature of FMF, children’s psychological adjustment may remain relatively stable, possibly because attacks are brief and treatment is largely based on non-invasive oral colchicine therapy. Moreover, the CD:H scale provided valuable insight by generating quantitative data while also reflecting children’s emotional experiences from their own perspectives.

Availability of data and materials

The data analyzed in this study are available from the corresponding author on reasonable request, subject to ethical approval.

Author contributions

AC—designed the research study. AC, BBA and MT—performed the research. HA—analyzed the data. MDD—wrote the manuscript. All authors reviewed and revised drafts and approved the final version for submission.

Ethics approval and consent to participate

All methods were performed in accordance with the guidelines and regulations contained in the Declaration of Helsinki and the STROBE guidelines. This study was approved by the Tokat Gaziosmanpaşa University Faculty of Medicine Non-Interventional Scientific Research Ethics Committee (Reference No: 25-MOBAEK-233). Signed consent forms were obtained from parents and children who agreed to participate.

Acknowledgment

The authors have no acknowledgments to report for this study.

Funding

The study was self-funded. No public or private funding source was used for this research.

Conflict of interest

The authors declare no conflict of interest.

Supplementary material

Supplementary material associated with this article can be found, in the online version, at https://oss.jocpd.com/files/article/2041767671739891712/attachment/Supplementary%20material.docx.