Cognitive Behavioral Therapy for Children and Adolescents with Dental Phobia

Background: Dental phobia is a disabling and clinically significant fear that interferes with the dental care necessary for a child’s or adolescent’s well-being. In fact, the definition of oral health in children and adolescents stresses, not only sound and well-functioning dental and oral structures, but also an absence of dental fear and anxiety. Cognitive behavioral therapy (CBT) is an evidence-based psychological treatment for specific phobias that has been used, to a limited extent, in pediatric dental care. Guided internet-based CBT (ICBT) is a variant of CBT that has emerged as an efficacious treatment for many psychiatric disorders, with results similar to face-to-face CBT. At the time of these studies, this new form of CBT had not been tested for dental phobia. Aims: The purpose of this thesis was to (i) explore how school-aged children and adolescents, and their parents, experience and benefit from CBT for dental phobia (Study I), (ii) test the hypothesis that CBT is more efficacious than treatment as usual for dental phobia in school-aged children and adolescents (Study II), and (iii) test the hypothesis that psychologist-guided ICBT improves the ability of school-aged children and adolescents to manage dental phobia, while also testing the feasibility and acceptability of a novel ICBT for pediatric dental phobia (Study III). Methods: The studies used both qualitative and quantitative research methods. Study I involved telephone interviews of 12 children (7–18 years) who had received CBT and one parent of each participant, with data collected and analyzed using qualitative methods. Study II employed a randomized controlled design to evaluate 30 children referred from general dentistry to pediatric specialist clinics with a diagnosis of dental phobia. These children were randomized to either CBT or treatment as usual. Psychologists provided 10 hour-long sessions of CBT, based on a structured treatment manual. The primary outcome measure was the Behavior Avoidance Test (BAT). Other assessments included in Study II measured diagnostic status, fear, and self-efficacy. Study III was an open trial with parent-referred participants. It included 18 participants (8–15 years) with a diagnosis of dental phobia. Participants received psychologist-guided ICBT comprising 12 chapters of texts, animations, and dentistry-related video clips. The treatment also included visits and training at dental clinics and participants received an exercise package of dental instruments. The primary outcome measure for Study III was the picture-based BAT. Other assessments for dental phobia included in the study measured the diagnostic status, fear, negative thoughts, and child and parental self-efficacy. Assessments in Studies II and III occurred before treatment (baseline) and immediately after treatment (3 months), as well as at a 1-year follow-up. Study II analyzed both within-group and between-group changes, while Study 3 only analyzed within-group changes. Results: Analysis of the interviews in Study I showed that CBT led to a perspective shift, which means that children experienced mastery, feelings of safety, and reduced fear in a dental context. According to the participants, the new experiences of dental care was mediated by CBT and arose from gradual exposure, increased autonomy and control, therapeutic alliance, changed appraisal, reduced anticipatory anxiety, and access to new coping strategies. Overall the parents’ and children’s experiences of CBT were positive. Study II showed larger improvements in the CBT group compared to treatment as usual. Results were statistically and clinically significant in both the primary and secondary outcome measures, both after treatment and at the 1-year follow-up. We found a large between-group effect size for the primary (Cohen’s d = 1.4 at post-treatment and 1.9 at the 1year follow-up) and secondary outcome measures. Results of Study III also showed large within-group effect sizes for the primary (Cohen’s d = 1.4 and 1.5) and secondary outcome measures. Within-group improvements for participants were statistically and clinically significant. Average clinician support time during the 12 weeks was 5.4±2.3 hours per participant and, on average, patients completed 9.2±3.3 treatment modules. Study III showed that ICBT for pediatric dental phobia is a feasible and acceptable treatment. Conclusions: School-aged children and adolescents with dental phobia who received CBT could benefit from the treatment. They experienced mastery, reduced fear, and increased feelings of safety, which helped them to change their view of dentistry and their own potential (perspective shift). CBT was more efficacious than treatment as usual. Children and adolescents in the CBT group improved more in their ability to manage dental procedures, and showed reduced anxiety and increased self-efficacy. Children and adolescents participating in a novel psychologist-guided internet-based CBT improved their ability to manage procedures in dental care. The children’s and adolescent’s dental fear and negative thoughts decreased while both participants and parents experienced increased self-efficacy. CBT is an efficacious treatment for children and adolescents with dental phobia and should be made accessible in pediatric dentistry. ICBT seems to have similar effects as face-to-face CBT. It has the potential to increase access to evidence-based psychological treatment. Important advantages that enable increased accessibility are that ICBT requires a limited amount of therapist time, that large geographic distances distance between therapist and patient is no obstacle, and that it does not require access to specialist pediatric dental care. The efficacy of ICBT needs to be confirmed in future randomized controlled trials. LIST OF SCIENTIFIC PAPERS I. Shahnavaz S, Rutley S, Larsson K, Dahllöf G. Children and parents’ experiences of cognitive behavioral therapy for dental anxiety a qualitative study. Int J Paediatr Dent 2015; 25(5): 317–326. II. Shahnavaz S, Hedman E, Grindefjord M, Reuterskiöld L, Dahllöf G. Cognitive behavioral therapy for children with dental anxiety: A randomized controlled trial. JDR Clinical & Translational Research 2016;1(3):234–243. III. Shahnavaz S, Hedman E, Hasselblad T, Kaldo V, Reuterskiöld L, Dahllöf G. Internet-based cognitive behavioral therapy for children and adolescents with dental anxiety An open trial. In manuscript.