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
Erickson modified the famous Freud’s theory by superimposing psychosocial and psychosexual factors that simultaneously contribute to the personality development of the child.
#Trust versus Mistrust (0-1 years) : This phase occupies the first year and is mainly concerned with the establishment of secure and stable relationships between mother and child. If successful outcome is there, then the child feels that the world is predictable, safe, and secure.
Its application in dental practice: This stage identifies with development of seperation anxiety in the child. So if it is necessary to provide dental treatment at this early age, it is preferable to do so with the parent holding the child.
#Autonomy versus Shame (1-2 years) :This phase is characterized by the child’s increasing powers of mobility and locomotor skills, providing the basis for the development of some independence and autonomy.
Its application in dental practice: Child is moving away from mother, but still will retreat to her in threatening situations. So, parent’s presence is essential in dental clinic.
#Initiative versus Guilt (2-6 years) :
- The child rapidly expands language skills so that exploration and activity is the order of the day.
- If the child’s exuberance and enthusiasm are too restricted by parents or others, then despondency and defeatism predominates, leaving the child with a sense of guilt.
Its application in dental practice: Child can be encouraged to view this visit as a new adventure and can be taught about various things in a dental clinic.
#Industry versus Inferiority (6-12 years): Schooling and peer relations predominate in this phase, so that successful child becomes literate, numerate and socially integrated.
Its application in dental practice Cooperation at this stage depends on whether he / she understands what is needed to please the dentist/parent, whether the peer group is supportive or not and whether the desired behavior is reinforced by the dentist.
#Identity versus Role confusion (12-18 years): Two tasks, sexual identity and career identity are the major forces of interest for the individual.
Its application in dental practice Behavior management of adolescents can be challenging. At this stage, external appearances are very important as it helps in attainment of intimate relations, these young adults seek orthodontic treatment to correct their dental appearance. Any orthodontic treatment should be carried out if child wants it.
Cognitive Theory by Jean Piaget
- A Swiss psychologist Jean Piaget has elaborated the most comprehensive theory of cognitive development.
- Piaget theorized that children’s knowledge about reality is realized by touching and observing; he termed this constructivism. Practitioners should try to stimulate these needs to develop a positive dental experience.
- Another Piaget model is egocentrism, wherein a child views the world subjectively. The dentist should let the child patient know what’s going on and have an active part in treatment.
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 or exposure therapy described by Wolpe is a valuable tool in managing dental anxiety and improving chair side behaviour as well.
- 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: The conditioning is affected if the person is aware of what is occuring.
- Consequent Determinants: Person’s perception and expectancy determine behavior.
- Modelling: Learning through observation eliminates the trial error search.
- Self regulation: This system involves a process of self regulation, judgements and evaluation of individual’s responses to his own behavior.
Its application in dental practice
Children are capable of acquiring almost any behavior that they observe closely and are not too complex for them to perform at the level of physical development. Observational learning is an important tool in management of dental treatment.
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, an individual who experiences a painful procedure (and the unconditioned response of anxiety/fear) during a dental visit may acquire a conditioned association between the dentist (the conditioned stimulus) and anxiety/fear (the conditioned response). Re-presentation of the conditioned stimulus (the dentist or related stimuli) is then able to elicit the conditioned response of anxiety during the patient’s next dental consultation.
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