Childhood dental anxiety is not only distressing for the child and his family, but is also associated with poor oral health outcomes and an increased stress on the general and specialist dentists. This article will discuss psychological approaches aimed at reduction of dental anxiety in children, which in-turn insures a stress free practice for dentist.
Importance of Child Psychology
- To understand the child better
- To know any problems of psychological origin
- To deliver dental treatments in a meaningful and effective manner
- To establish effective communication with the child and the parent
- To teach the importance of primary & preventive healthcare to the child and parents
- To have a better treatment planning and interaction with other medical or dental specialities
Child psychology theories can broadly be classified into two groups:
I) Psychodynamic Theories:
- Psychoanalytical Theory by Sigmund Freud (1905).
- Psychosocial Theory by Erik Erikson(1963).
- Cognitive Theory by Jean Piaget (1952).
II) Theories of learning and behavior development:
- Hierarchy Of Needs by Maslow (1954).
- Social Learning Theory by Bandura (1963).
- Classical Conditioning by Pavlov (1927).
- Operant Conditioning by Skinner (1938).
We will be discussing 5 theories in detail as they have the most relevant applications in a clinical dental setting.
Psychosocial Theory by Erik Erikson
Erikson’s theory of psychosocial development modified Freud’s original psychosexual theory by incorporating both psychosocial and psychosexual factors that contribute to a child’s personality development.
The first stage, Trust versus Mistrust (0-1 years), is focused on the establishment of secure and stable relationships between a mother and her child. If this stage is successfully navigated, the child feels that the world is safe, predictable, and secure.
In dental practice, this stage is relevant in the development of separation anxiety in children. To help alleviate anxiety during dental treatment, it is recommended to have the parent hold the child during procedures.
The second stage, Autonomy versus Shame (1-2 years), involves the child’s increasing mobility and locomotor skills, which form the basis for the development of independence and autonomy.
In dental practice, this stage is characterized by the child moving away from their mother but still seeking refuge with her in threatening situations. Hence, the presence of the parent in the dental clinic is crucial to provide the child with a sense of security and comfort.
Overall, Erikson’s theory underscores the importance of understanding a child’s developmental stage to effectively address their psychological needs in various settings, including dental clinics.
Erikson’s theory of psychosocial development also includes several stages that occur during childhood and adolescence.
The third stage, Initiative versus Guilt (2-6 years), is characterized by the child’s rapid expansion of language skills and increasing exploration and activity. To avoid feelings of guilt, parents and others must allow children to express their exuberance and enthusiasm. In dental practice, children can be encouraged to view dental visits as a new adventure, and they can be taught about various aspects of dental care in a positive and engaging way.
The fourth stage, Industry versus Inferiority (6-12 years), focuses on schooling and peer relations. Successful children become literate, numerate, and socially integrated. In dental practice, cooperation at this stage depends on the child’s understanding of what is required to please the dentist/parent, the supportiveness of their peer group, and whether desired behavior is reinforced by the dentist.
The fifth stage, Identity versus Role Confusion (12-18 years), involves two major tasks: sexual identity and career identity. At this stage, external appearances are particularly important for establishing intimate relationships. Adolescents may seek orthodontic treatment to improve their dental appearance.
Erikson’s theory emphasizes the importance of understanding a child’s developmental stage and meeting their psychological needs in various settings, including dental clinics.
When it comes to orthodontic treatment, it is crucial to consider the child’s desire for treatment and their ability to understand the implications of the procedure. Informed consent is essential, and both the child and their parent or guardian should fully understand the potential benefits and risks of treatment.
By taking a holistic approach to dental care and considering a child’s developmental stage and unique needs, dental professionals can help promote positive outcomes and establish a foundation for good oral health throughout the patient’s life.
Cognitive Theory by Jean Piaget
- Piaget believed that children progress through distinct stages of cognitive development, each characterized by a different way of thinking about and understanding the world. These stages include the sensorimotor stage (birth to 2 years), the preoperational stage (2 to 7 years), the concrete operational stage (7 to 11 years), and the formal operational stage (11 years and up).
- In the context of dentistry, Piaget’s constructivist approach suggests that children learn best by actively engaging with their environment, and that practitioners can help facilitate this learning by providing hands-on opportunities for exploration and discovery.
- Piaget’s concept of egocentrism refers to the tendency of young children to view the world from their own perspective, without fully understanding the viewpoints of others. In the dental setting, this means that practitioners should take care to communicate clearly with child patients and involve them in the treatment process, helping them to understand what is happening and why. This can help children feel more confident and comfortable during their dental visits.
The cognitive stage development has been categorized into 4 stages:
A) Sensorimotor stage (0-2 years) : Coordination reflexes. During this period, infants primarily engage in sensorimotor thoughts i.e., thoughts based on sensory input and physical or motor actions. The child at this stage is only capable of direct action on the world.
Its application in dental practice (0-2 years):
- Children up to two years of age are considered to lack the ability to cooperate due to their limited cognitive development. Hence, general anaesthesia or delaying of elective treatment is preferred. General anaesthesia or restraints may be performed for emergency treatment.
- After eighteen months of age, communication, distraction and tell-show-do may be tried as the child begins to show some evidence of symbolic behaviour. However, the success rates of these behaviour management strategies are not good as the child’s language and cognitive skills are yet to develop.
B) Preoperational stage (2-7 years): self oriented, ego centric.
Its application in dental practice (2-7 years):
- Tell-show-do with the correct use of euphemisms fit to child’s vocabulary (by 2 years – 250 words; by 5 years – 2000 words) Eg: slow piece handpiece may be called ‘uncle bumpy’ as the vibrations produced feel like bumps to the child, pre-visit imagery make them imagine how the visit would be.
- Tell-play-do; Pre and post-appointment games involving the child pretending to be a dentist with a toy dental kit helping in reduction of anxiety (pre-visit), reinforcing oral hygiene instructions (post-visit)
- To take advantage of a child’s egocentrism in the dental clinic, effective communication with the correct use of euphemisms as well as rewarding the child by praising them in front of their parents or peers is effective in developing a positive attitude.
- Allowing them to play an active role in the treatment process by asking them to perform seemingly important activities such as holding the suction tip or temporarily pausing the treatment when they raise their hand makes them feel involved and improves their chair side behaviour.
- Distraction; Use of audio-visual aids, virtual reality, and 3D glasses
- Aroma and music therapy for relaxation and distraction; Use of injection sleeves.
- Establish dentist as authority figure to be obeyed; Voice control
- Direct observation; Reinforcements (E.g.: notice board with photographs of ‘good’ children), parental presence/absence.
C) Concrete operational stage (7- 12 years) : Children reaching this stage are capable of logical thought, reversibility of schemes, and have the ability to consider more than one aspect of a situation. However, the logic remains limited to concrete and tangible materials and experience, no abstract problems.
Its application in dental practice (7- 12 years)
- Relaxation techniques including training exercises such as bubble breath exercises have been proven to effectively reduce anxiety during buccal infiltration injections. Other relaxation techniques including Jacobson’s progressive relaxation learning and computer- assisted relaxation learning, are also effective in reducing dental anxiety thereby improving chair side behaviour, attitudes and quality of treatment provided.
- Systematic desensitization or exposure therapy initially described by Wolpe is based on relaxation and encourages children to discuss their status of anxiety and fear in order to construct a hierarchy of their most feared dental situations and to gradually expose them to these situations from the least to most anxiety producing.
- Guided imagery has also been utilized successfully to give local anaesthesia to children as helping in reducing fear from the syringe and gaining better compliance from the child.
- Teach back technique for children in concrete operations has been observed to be beneficial for reinforcing patient education, improved follow-ups, and overall health outcomes.
- Distraction methods have been studied as effective in managing children in the concrete operations stage including virtual reality, 3D videos, and other audio-visual aids by various authors and researchers
D) Formal operational stage (above 11 or 12 years) : think abstractly, reason theoretically, not all people reach this stage.
Its application in dental practice (above 11 or 12 years)
- Contemporary behaviour management techniques that gain from logical thought include biofeedback i.e., a mind- body technique assisting the patient to attain self-regulation and control thereby encouraging improved behaviour in the dental setting.
- Systematic desensitization is a type of cognitive-behavioral therapy that involves gradually exposing the patient to the feared stimulus while teaching relaxation techniques to reduce anxiety. The goal is to help the patient learn how to cope with their fear and eventually overcome it. This therapy can involve creating a hierarchy of feared stimuli associated with dental treatment, such as sitting in the waiting room, lying back in the dental chair, or having an injection, and then gradually exposing the patient to each item on the hierarchy while using relaxation techniques to manage anxiety.
- Cognitive behaviour therapy involving learning to effectively change negative and distorted thoughts and actions into more positive ones helps alleviate anxiety and promote a better dental experience.
- Guided imagery, teach-back and relaxation techniques are useful in managing the behaviour of children in their formal operational thought period.
- Gaining advantage from adolescent egocentrism, teenagers can be motivated using esthetic models for various treatments including orthodontic corrections.
- Providing positive reinforcement along with problem ownership and good communication skills can improve behaviour and help in providing quality dental treatment.
Social Learning Theory
It is thought to be the most complete, clinically useful and theoretically a sophisticated form of behavior therapy.
THE LEARNING OF BEHAVIOR IS AFFECTED BY 4 PRINCIPAL ELEMENTS:
- Antecedent Determinants: This refers to the environmental or situational factors that precede and influence behavior. For example, a person’s behavior may be affected by their perception of the situation, their mood, or their past experiences.
- Consequent Determinants: This refers to the consequences that follow a behavior, which can either reinforce or discourage that behavior in the future. For instance, if a patient receives positive feedback after successfully completing dental treatment, they may be more likely to repeat this behavior in the future.
- Modelling: This involves learning through observation and imitation of others. Patients can learn from watching others undergo dental procedures, which can reduce fear and anxiety associated with dental visits.
- Self-regulation: This involves an individual’s own judgements and evaluations of their behavior. For example, a patient may self-evaluate their anxiety levels during dental treatment and use relaxation techniques to manage it.By understanding these four elements, dental professionals can develop effective strategies for helping patients overcome dental anxiety and improve their overall experience during dental procedures.
Its application in dental practice
In the context of dental treatment, observational learning can be used to help children acquire the skills and behaviors necessary for successful dental visits. For example, a child who observes another child having a positive experience during a dental appointment may be more likely to feel comfortable and confident during their own visit.
However, it’s important to note that not all behaviors are appropriate for children to observe or imitate. Practitioners should take care to model only appropriate behaviors and attitudes in the dental setting, and to provide clear guidance and instruction to children to ensure that they are able to perform any observed behaviors safely and effectively.
Overall, observational learning can be a valuable tool in the management of dental treatment, helping to promote positive behaviors, attitudes, and experiences for child patients.
Classical Conditioning Theory
Classical or Pavlovian conditioning refers to the process by which a previously neutral stimulus acquires the ability to directly elicit a response through pairing this stimulus with another unconditioned stimulus that elicits the same response.
For example, if a patient experiences a painful procedure during a dental visit, they may develop a conditioned association between the dentist (the conditioned stimulus) and anxiety/fear (the conditioned response). This means that the dentist becomes associated with the negative experience, so just thinking about or being in the presence of the dentist can trigger feelings of anxiety or fear.
This type of learned response can persist and generalize to other situations related to dental care, such as the dental office environment or even the sound of a dental drill. It can also lead to avoidance behavior, where the patient puts off necessary dental care altogether due to anxiety and fear.
Understanding classical conditioning theory can help dental professionals develop effective strategies for managing patient anxiety and reducing the likelihood of developing conditioned fear responses. These strategies may include providing a relaxed and calming environment, using distraction techniques during procedures, and providing patients with positive reinforcement after successful completion of dental treatment.
Operant Conditioning Theory
The principle of this theory arise from experimental work of Skinner.
He described 4 basic types of operant conditioning distinguished by the types of consequences.
- POSITIVE REINFORCEMENT: If a pleasant consequence follows a response, the response is a positively reinforced and the behavior that lead to this pleasant consequence becomes more likely in the future.
- NEGATIVE REINFORCEMENT: It involves the withdrawal of an unpleasant stimulus after a response.
- OMISSION(TIME OUT) : It involves the removal of a stimulus after a particular response.
- PUNISHMENT: It occurs when an unpleasant stimulus is presented after a response. This also decreases the probability that behavior that punishment will occur in the future.
Its application in dental practice
Operant conditioning is the procedure of presenting a reinforcing stimulus immediately following the occurrence of a given response. Conditioning is said to occur if and only if the response then increases in rate of occurrence, magnitude, or relative frequency, or decreases in latency as a consequence of the operation.
For phobias, the process of positive punishment (e.g., pain and anxiety that occurs during a visit to the dentist) and negative reinforcement (e.g., the reduction in anxiety that results when the individual avoids the dentist) are thought to be most important and must be taken care of.
- Communication: listen, ask, assess, acknowledge and address
- Shaping: praise for attending, for complying and completing treatment
- Stop signalling: the patient raises a hand if they need a break (increases control)
- Modelling: seeing a sibling complying with treatment in children
- Distraction: breath control, legs up, physical or mental distraction
- Tell-show-do: increases predictability
- Flooding/implosion: repeatedly exposing patients to the conditioned stimulus until the conditioned response is terminated
Anxiety, fear and perceived stress in the dental setting are common worldwide. These problems are present excessively in pediatric dental practice. Applying principles of child psychology in pediatric dentistry helps the dental clinical practitioner in behavior management techniques based on psychological approaches.
Author – Dr Mriganka Sekhar Ghose