Management of children's dental anxiety

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Figure 1. Five Areas approach of dental anxiety (adapted from Williams & Garland’s Five Areas approach of CBT assessment and management )

Five Areas Cognitive Behavioural Therapy approach

The Five Areas approach of CBT is designed to help practitioners assess how the patient’s life situation, thoughts/worries, behaviours, emotions and physical symptoms feed into their experience of anxiety. The purpose of the assessment is to help the practitioner and patient understand how these five areas inter-relate (creating a vicious circle of anxiety) and which area/s should the target for intervention (to ‘break’ the vicious circle of anxiety) . The factors which contribute to an individual’s dental anxiety will determine the most appropriate intervention for reducing the anxiety . For example, a child who is fearful and avoidant of specific dental stimuli may be better suited to a behavioural intervention (e.g. graded exposure) than a child who holds irrational thoughts about the dentist (e.g. ‘the dentist will shout at me’. There is, however, an overlap between the different groups of interventions and a combination of psychological strategies are often employed to reduce children’s anxiety (e.g. graded exposure with cognitive restructuring) . It should also be recognised that an intervention which targets one area (e.g. promotes more adaptive behaviour) is likely to have a positive effect on others areas of the child’s anxiety (e.g. increases positive cognitions). The Five Areas model will be used within this paper to provide a framework for describing a variety of psychological approaches available for the reduction of children’s dental anxiety (Figure 1).

Children’s life situation

There may be many aspects of the child’s life situation and/or their external environment which could be contributing to their dental anxiety. However, parental anxiety has perhaps received the most attention within the literature as an important external factor which may influence the child’s anxiety and behaviour within the dental setting . Providing parents with procedural information about their child’s dental treatments has been found to be an effective intervention in reducing the pre-operative anxiety of parents . The involvement of the child’s parents should also be a key consideration when delivering psychological interventions for children. Parents can learn about helpful and unhelpful approaches for managing their child’s anxious symptoms and behaviours. For example, parents learn not to pressurise children into a feared situation but also not to facilitate avoidance by allowing children to avoid feared stimuli . There is indeed evidence that through watching their child’s progress, parents can learn how to coach children in future anxiety provoking situations .

Children’s altered thoughts

Extreme or negative thinking can also contribute to increased anxiety as unhelpful thinking styles undermine an individual’s perceived ability to cope with a situation . Unhelpful thinking styles may include extreme or catastrophic thinking about the dental encounter/procedure (e.g. ‘I might choke’) or mind-reading and jumping to conclusions (e.g. ‘the dentist won’t understand my fear and will think I’m silly’). Cognitive restructuring refers to a child being taught to recognise the negative thoughts which precipitate their anxiety and replace these with more helpful cognitions . Research has revealed promising results in the use of cognitive strategies to reduce adults dental anxiety , however, there has been a paucity of research investigating the effectiveness of cognitive interventions in reducing children’s dental anxiety.

Children’s altered physical feelings/symptoms

There are a variety of relaxation techniques which can be used with children with dental anxiety such as controlled breathing and progressive muscle relaxation. Relaxation techniques can be used to reduce the physical tension in the anxious patient and teach the individual how to gain control over the physical symptoms caused by their dental anxiety, if this is an area which the individual experiences difficulties in . Pre-appointment preparations such as encouraging children to view audiovisual products and audiovisual distraction are techniques which have also been used to help relax children and reduce their anxiety levels .

The technique of ‘Applied tension’ can be used with patients who may have a tendency to faint during the dental encounter. Within this technique patients are taught how to apply tension to their muscles to increase their blood pressure and reduce the likelihood of fainting . There is evidence that needle phobia may be a separate phenomenon to generalised dental anxiety and it should be recognised that a proportion of children who present with needle phobia may actually be Blood-Injury-Injection phobic. In this group of children it may be the fear of fainting which is precipitating their feelings of anxiety . Exploring the anxious child’s physical symptoms can provide the dental practitioner with an insight into the nature of the child’s fear and the type of intervention which may be most appropriate for their situation.
Children’s altered behaviours

Anxiety can result in people employing behaviours which, whilst may reduce their anxiety in the short term (e.g. avoidance), will further worsen how they feel in the long term . Avoidance behaviours can undermine self-confidence and reinforce negative thoughts and therefore a number of behavioural interventions are designed to challenge these unhelpful behaviours and enable individuals to face their fears. Behavioural interventions such as graded exposure to the feared stimuli and modelling are recognised as treatments with the most substantial evidence base for patients with specific phobias .

Graded exposure and systematic desensitization are techniques which are based on the principle that a patient can overcome their if they are gradually exposed to the feared stimuli in a controlled and systematic way (in vitro or in vivo). Exposure to the feared stimuli or situation is recognised as a central treatment component for specific phobias . It is thought that exposure to a feared stimuli helps individuals overcome their anxiety in three ways: i) encouraging habituation to the feared stimuli; ii) allowing for active elicitation and challenging of catastrophic thoughts associated with the feared stimuli and, iii) preventing behavioural and cognitive avoidance .
Graded exposure involves the patient developing a ‘hierarchy’ of their feared stimuli/situations. Patients are first exposed to their least feared stimuli/situation and are then required to remain in that situation until their level of fear significantly decreases. This process is repeated and only when the patient is no-longer fearful of that stimuli/situation does patient move on to next item in their fear hierarchy . The stages of the fear hierarchy could progress from the child looking around the dental surgery at the lowest level to accepting a dental injection at the highest level . Graded exposure interventions have been found effective in improving the coping strategies and reducing anxiety levels of children suffering from anxiety and specific phobias . To date, there has been a paucity of high-quality research into the effectiveness of graded exposure in children with dental anxiety, however, case studies have provided some evidence that this type of intervention can be highly effective for children with dental anxiety . The technique of systematic desensitization, developed from Wolpe’s original conceptualisation of desensitisation, shares many of the features of graded exposure, however, this techniqe highlights the role of counter-conditioning though the pairing of the graded feared stimuli with a neutral or positive stimulus (e.g. relaxation or emotive imagery) .
Child patients may also learn how to cope with the feared dental situation through the process of modelling. Modelling is based on Bandura’s Social Learning Theory and refers to an indirect learning process whereby patients develop effective coping skills by observing other people (e.g. other children, parents) successfully receiving dental treatment (film, in-vivo) . Modelling can also be used to provide an additional structure to graded exposure experiments in which the therapist may demonstrate each incremental step prior to the client carrying out the interaction with the phobic object or situation . Whilst a series of studies have found modelling to be a useful intervention in improving the behaviour of anxious children in the dental setting , only one in ten paediatric dentists report using live modelling techniques in their practice .
Children’s altered emotions

The Five Areas model encourages practitioners to explore the patient’s emotions and subjective experiences associated with their anxiety . For example, whilst some children may experience a general anxiety towards the dental situation other children may be fearful of specific dental stimuli. Many self-report measures of children’s dental anxiety are available to help identify the nature of the child’s anxiety/fear . It is also possible that children may experience a variety of other emotions associated with their dental anxiety or the dental situation (e.g. feelings of embarrassment or humiliation). Assessment of this area will aid the dental practitioner’s understanding of the emotional impact of the child’s dental anxiety.

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