Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental Anxiety: Open Trial

Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental or Injection Phobia: Randomized Controlled Trial

BACKGROUND

Dental phobia (DP) and injection phobia (IP) are common in children and adolescents and are considered some of the biggest obstacles to successful treatment in pediatric dentistry. Cognitive behavioral therapy (CBT) is an evidence-based treatment for anxiety and phobias. As the availability of CBT in dentistry is low, internet-based CBT (ICBT) was developed. Open trials have shown that ICBT is a promising intervention, but randomized trials are lacking.

OBJECTIVE

This randomized controlled trial tests whether therapist-guided ICBT supported by a parent could reduce fear, allowing children and adolescents with DP or IP to receive dental treatment.

METHODS

We enrolled 33 participants (mean age 11.2, SD 1.9 y) whom a clinical psychologist had diagnosed with DP, IP, or both. After inclusion, participants were randomized to either ICBT (17/33, 52%) or a control group of children on a waitlist (16/33, 48%). ICBT was based on exposure therapy and comprised a 12-week at-home program combined with visits to their regular dental clinic. Participants corresponded weekly with their therapist after completing each module, and 1 parent was designated as a coach to support the child in the assignments during treatment. All participants completed measurements of the outcome variables before treatment start and after 12 weeks (at treatment completion). The measurements included a structured diagnostic interview with a clinical psychologist. Our primary outcome measure was the Picture-Guided Behavioral Avoidance Test (PG-BAT), which assesses the ability to approach 17 dental clinical procedures, and a positive clinical diagnosis. Secondary outcome measures included self-report questionnaires that measured self-efficacy and levels of dental and injection anxiety. The children and their parents completed the questionnaires.

RESULTS

All participants underwent the 12-week follow-up. After treatment, 41% (7/17) of the participants in the ICBT group no longer met the diagnostic criteria for DP or IP, whereas all participants in the control group did (P=.004). Repeated-measure ANOVAs showed that ICBT led to greater improvements on the PG-BAT compared with the control group; between-group effect sizes for the Cohen d were 1.6 (P<.001) for the child-rated PG-BAT and 1.0 (P=.009) for the parent-rated PG-BAT. Reductions in our secondary outcomes-dental fear and anxiety (P<.001), negative cognitions (P=.001), and injection fear (P=.011)-as well as improvements in self-efficacy (P<.001), were all significantly greater among children in the ICBT group than in the controls. No participants reported adverse events.

CONCLUSIONS

ICBT seems to be an effective treatment for DP and IP in children and adolescents. It reduced fear and anxiety and enabled participants to willingly receive dental treatment. ICBT should be seriously considered in clinical practice to increase accessibility; this therapy may reduce the need for sedation and restraint and lead to better dental health in children and adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02588079; https://clinicaltrials.gov/study/NCT02588079.

Reducing Dental Anxiety in Children Using a Mobile Health App: Usability and User Experience Study

BACKGROUND

Dentistry interventions cause common anxiety and fear problems in children (6-11 years), and according to scientific evidence, this causes a decrease in their quality of life. Therapies mediated by IT-based tools have been shown to positively influence children's mood based on distraction as well as relaxing activities, but there is no evidence of their use to reduce dental anxiety in children.

OBJECTIVE

The aim of this study was to answer the following research question: Does our new children-centered codesign methodology contribute to achieving a usable mobile-based product with a highly scored user experience?

METHODS

A mobile health app was developed to reduce dental anxiety in children using rapid application development following the usage-centered design methodology. Structured interviews were conducted to test the usability and user experience of the app prototype among 40 children (n=20, 50%, boys and n=20, 50%, girls; age 6-11 years) using a children-adapted questionnaire and the 7-point Single Ease Question rating scale. The Smiley Faces Program-Revised questionnaire was used to assess the level of dental anxiety in participants.

RESULTS

There were no significant differences between girls and boys. The task completion rate was 95% (n=19) for children aged 6-8 years (group 1) and 100% (n=20) for children aged 9-11 years (group 2). Group 1 found watching the relaxing video (task C) to be the easiest, followed by playing a video minigame (task B) and watching the narrative (task A). Group 2 found task C to be the easiest, followed by task A and then task B. The average time spent on the different types of tasks was similar in both age groups. Most of the children in both age groups were happy with the app and found it funny. All children thought that having the app in the waiting room during a dental visit would be useful.

CONCLUSIONS

The findings confirmed that the app is usable and provides an excellent user experience. Our children-adapted methodology contributes to achieving usable mobile-based products for children with a highly scored user experience.

Experiences of Parental Presence in the Induction of Anesthesia in a Canadian Tertiary Pediatric Hospital: A Cross-Sectional Study

Background Parental presence at induction of anesthesia remains controversial and has been reported to provide mixed results. As such, parental presence at induction of anesthesia is not practiced routinely everywhere. There are currently limited data describing the practice of parental presence at induction of anesthesia or the experiences and perceptions of parents in Canada. Objectives We sought to investigate (1) the frequency of parental presence at induction of anesthesia and (2) the experiences and perceptions of parents accompanying their child into the operating room compared to those who did not at a tertiary Canadian pediatric hospital. Methods Institutional quality improvement approval was obtained. This study was a cross-sectional survey. Parents waiting in the parent surgical waiting room during the procedure were invited to complete a web-based survey. Consent was implied via completing the survey. The cross-sectional survey elicited the prevalence of parental presence during induction of anesthesia as well as their experience and perceptions. We also investigated the parents' preferences for preoperative education. Results Of the 448 parents approached, 403 completed the survey between May and June 2017. Sixty-eight (16.9% [13.4-20.9]) parents accompanied their child into the operating room (parental presence at induction of anesthesia), while 335/403 (83.1% [79.1-86.7]) did not (no-parental presence at induction of anesthesia). Reasons for not accompanying their child into the operating room included "not being aware they could" (158/335, 47.2% [41.9-52.5]), "I didn't think my child needed me" (107/335, 31.9% [27.2-37.1]), "my child was coping well" (46/335, 13.4% [10.5-17.8]), and "I was anxious" (47/335, 14.0% [10.7-18.2]). Most of the parents in the parental presence at induction of anesthesia cohort (66/67, 98.5% [95.6-101.2]) reported that they believed their child benefited/would have benefited from their presence during induction of anesthesia compared to those in the no-parental presence at induction of anesthesia cohort (137/335, 40.9% [35.8-46.2]), P < 0.001. Overall, 51/335 (14.7%) parents in the no-parental presence at induction of anesthesia cohort and 3/67 (4.5%) of those in the parental presence at induction of anesthesia cohort felt that offering parental presence at induction of anesthesia should depend on factors including child's age as well as the level of coping and anxiety. More patients in the no-parental presence at induction of anesthesia cohort felt that parental presence at induction of anesthesia should also depend on the child's age and whether the child was coping. Parents felt that face-to-face discussions with clinicians are most effective for discussing future parental presence at induction of anesthesia. Conclusions We have shown that most parents at our institution do not undergo parental presence at induction of anesthesia and are for the most part comfortable with their child going unaccompanied into the operating room. Administrators and clinicians seeking to implement parental presence policies should consider navigating parental presence at induction of anesthesia with evidence-based approaches tailored to each parent and their child.

Cognitive-behavioral therapy on psychological stress and quality of life in subjects with pulmonary tuberculosis: a community-based cluster randomized controlled trial

Background

Anxiety and depression are two common psychological disorders in patients with pulmonary tuberculosis. We aimed to explore the effects of cognitive-behavioral therapy (CBT) on psychological stress and quality of life in patients with pulmonary tuberculosis.

Methods

From September 2018 to November 2018, 20 communities (461 participants in total) were randomly assigned in an intervention or control group following a two-level cluster random design. The intervention group underwent CBT for 2 months, whereas the control group received routine follow-up. Anxiety, depression, and quality of life were assessed using the Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder questionnaire (GAD-7), and 36-Item Short-Form Health Survey (SF-36) scales, respectively. Comparisons between the two groups were conducted using independent samples t-tests, and differences between the two groups before and after treatment were analyzed using paired samples t-tests.

Results

There were a total of 454 participants in the final analysis. After 2 months of CBT intervention, the CBT group had a GAD-7 score that was 1.72 lower than the control group (1.47–1.99, p < 0.001), a PHQ-9 score of the CBT group that was 2.05 lower than that of the control group (1.74–2.37, p < 0.001). The CBT group had a total SF-36 score that was 10.7 lower than that of the control group (95% CI: 7.9–13.5, p < 0.001). In patients with different degrees of anxiety and depression, only those in the intervention group who had mild and moderate anxiety and depression symptoms showed a significant reduction in anxiety and depression scores following the intervention.

Conclusions

CBT can relieve anxiety, and depression symptoms and increase the quality of life in subjects with pulmonary tuberculosis.

Trials registration

ChiCTR-TRC-12001958 Date of Registration: 22/02/2012.

Association of dental caries with use of internet and social media among 12 and 15-year-olds

OBJECTIVES

To investigate the association of dental caries with use of internet and social media to gain information on oral health and to evaluate the impact of this practice on oral health inequalities among 12 and 15-year-olds.

METHODS

Data from the Children's Dental Health Survey (CDHS) 2013, England Wales and Northern Ireland were used. The survey included sociodemographic, health behaviours, use of internet and social media, and clinical dental data. The association between the prevalence of caries experience (DMFT ≥ 1) and the number of untreated dental decay with use of internet and social media was assessed adjusting for age, gender, country, deprivation, toothbrushing, dental visits and consumption of sugary drinks and food.

RESULTS

A total of 4414 children were included in the analysis. Children who reported using internet and social media to gain information on oral health had significantly higher odds for caries experience (1.29, 95%CI: 1.03-1.62) in the model adjusting for age, gender and country. After adjusting for behavioural and socioeconomic factors the relationship remained positive, but not statistically significant. The use of internet and social media was not significantly associated with the number of untreated caries. Social gradients in oral health remained significant after adjusting for use of internet and social media.

CONCLUSIONS

The association between use of internet and social media, and dental caries could be mediated by health behaviours. Younger adults and children may be using the Internet and social media seeking information on dental caries, but longer online hours may also increase the caries risk. Internet-based health interventions should be supported by preventive strategies to promote effective and positive internet use.

The Relationship between Dental Fear and Anxiety, General Anxiety/Fear, Sensory Over-Responsivity, and Oral Health Behaviors and Outcomes: A Conceptual Model

Dental fear and anxiety (DFA) is common across the lifespan and represents a barrier to proper oral health behaviors and outcomes. The aim of this study is to present a conceptual model of the relationships between DFA, general anxiety/fear, sensory over-responsivity (SOR), and/or oral health behaviors and outcomes. Two rounds of literature searches were performed using the PubMed database. Included articles examined DFA, general anxiety/fear, SOR, catastrophizing, and/or oral health behaviors and outcomes in typically developing populations across the lifespan. The relationships between the constructs were recorded and organized into a conceptual model. A total of 188 articles were included. The results provided supporting evidence for relationships between DFA and all other constructs included in the model (general anxiety/fear, SOR, poor oral health, irregular dental attendance, dental behavior management problems [DBMP], and need for treatment with pharmacological methods). Additionally, SOR was associated with general anxiety/fear and DBMP; general anxiety/fear was linked to poor oral health, irregular attendance, and DBMP. This model provides a comprehensive view of the relationships between person factors (e.g., general anxiety/fear, SOR, and DFA) and oral health behaviors and outcomes. This is valuable in order to highlight connections between constructs that may be targeted in the development of new interventions to improve oral health behaviors and outcomes as well as the experience of DFA.

An internet-based treatment for flying phobia using 360° images: A feasibility pilot study

BACKGROUND

More research is needed in the field of Internet-delivered Cognitive Behavioral Treatments (ICBTs) for specific phobia in order to understand which characteristics are important in online exposure scenarios. The aim of the present work was to conduct a feasibility pilot study to explore participants' opinions, preferences, and acceptability ratings of two types of images (still images vs 360° navigable images) in an ICBT for Flying Phobia (FP). A secondary aim was to test the potential effectiveness of the two active treatment arms compared to a waiting list control group. An exploratory aim was to compare the role of navigable images vs. still images in the level of sense of presence and reality judgment and explore their possible mediation in treatment effectiveness.

METHODS

Participants were randomly allocated to three conditions: NO-FEAR Airlines with still images (n = 26), NO-FEAR Airlines with still and navigable images (n = 26), and a waiting list group (n = 26). Primary outcome measures were participants' opinions, preferences, satisfaction, and acceptance regarding the images used in the exposure scenarios. Secondary outcome measures included FP symptomatology outcomes and measures of sense of presence and reality judgment.

RESULTS

Participants in the study preferred navigable images over still images before and after treatment (over 84%), and they considered them more effective and logical for the treatment of their problem. However, adherence in the experimental conditions was low (42.3% dropout rate), and more participants withdrew from the group that included navigable images compared to the group that only included still images (14 vs. 8), with no statistical differences in attrition between the two conditions. NO-FEAR Airlines proved to be effective in reducing FP symptomatology compared to the control group, with large between-group effect sizes on all FP measures (ranging from 0.76 to 2.79). No significant mediation effect was found for sense of presence or reality judgment in treatment effectiveness.

DISCUSSION

The results of the current study suggest that participants prefer more immersive images in exposure scenarios, providing data that can help to design useful exposure scenarios to treat specific phobias in the future. They also provide evidence supporting the effectiveness of an ICBT for FP.

TRIAL REGISTRATION

Registered at Clinicaltrials.gov (NCT03900559) on April 9, 2019. Retrospectively registered.

Evaluation of the effectiveness of a mobile application in the management of dental anxiety: a randomized controlled trial

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a specially designed mobile application developed to provide patients with a sense of anxiety control during the various stages of endodontic treatment. The patients' anxiety was assessed by measuring their salivary cortisol levels.

METHODS

A total of 46 patients requiring endodontic treatment were recruited. The patients were randomly assigned to two groups. The experimental group used the special communication application, while the control group did not. Salivary samples were collected from all patients preoperatively, postanesthesia, and postoperatively. The samples were analyzed with an enzyme-linked immunosorbent assay to measure the cortisol levels.

RESULTS

A significant difference in cortisol levels was observed between the experimental and the control group (Mann-Whitney U test, P < .05). This difference was significant in the experimental group in each step (P < .01). No difference was found in the control group steps (P > .05).

CONCLUSIONS

Perceived control of anxiety using the specially designed software was effective in reducing salivary cortisol levels.

Internet- and mobile-based interventions for the treatment of specific phobia: A systematic review and preliminary meta-analysis

Internet- and mobile-based interventions (IMIs) are being developed for a wide range of psychological disorders and they showed their effectiveness in multiple studies. Specific phobia (SP) is one of the most common anxiety disorders, and research about IMIs for their treatment has also been conducted in recent years. The aim of this paper was to conduct a systematic review and preliminary meta-analysis exploring IMIs for the treatment of SP. A comprehensive search conducted in five different databases identified 9 studies (4 pre-post studies, 5 randomized controlled trials) with 7 Internet-based interventions and 2 mobile-based interventions. Results showed that exposure was the main component of all interventions, and that animal phobia was the most common subtype. Samples included children, adolescents, and adults. A preliminary meta-analysis of the included studies showed that participants receiving IMIs experienced a significant reduction of SP symptoms from pre- to post-treatment (g = 1.15). This systematic review found that there is already some evidence in the literature supporting the potential benefits of IMIs for SP. However, the number of studies included is small and more research should be carried out in the field.

Dentist-patient communication on dental anxiety using the social media: A randomized controlled trial

The purpose of the present study was to assess the effects of dentist-patient communication via social media on dental anxiety and to determine the appropriate timing of such communications. In this randomized, double-blinded and controlled trial, we used Instagram's quick replies system to answer patients' questions to alleviate dental anxiety for patients undergoing impacted teeth extraction under local anesthesia. Patients were assigned randomly into four groups according to the timing of such communications: only after (group 1, n = 36), only before (group 2, n = 35), before and after the operation (group 3, n = 36), and a control group who received no communication on social media (group 4, n = 36). Dental anxiety was evaluated one week before (pre-op) and after the operation (post-op) using recognized assessment scales -the Spielberger's State-Trait Anxiety Inventory, Modified Dental Anxiety Scale (MDAS), and Visual Analogue Scale (VAS). The results showed that the post-op values of group 4 had higher anxiety scores than the groups 2 and 3 according to VAS (p < 0.05). Within the groups, the anxiety levels showed a decreasing trend after surgery according to MDAS and VAS scores (p < 0.05). The results of this study suggest that communication with patients before the operation is sufficient to reduce their dental anxiety.

An Internet-based treatment for Flying Phobia using 360° images: Study protocol for a feasibility pilot study

BACKGROUND

Flying Phobia (FP) is a prevalent disorder that can cause serious interference in a person's life. ICBT interventions have already shown their efficacy in several studies, but studies in the field of specific phobias are still scarce. Moreover, few studies have investigated the feasibility of using different types of images in exposure scenarios in ICBTs and no studies have been carried out on the role of sense of presence and reality judgement. The aim of the present study is to explore the feasibility of an ICBT for FP (NO-FEAR Airlines) using two types of images with different levels of immersion (still and navigable images). A secondary aim is to explore the potential effectiveness of the two experimental conditions using two types of images compared to a waiting list control group. Finally, the role of navigable images compared to the still images in the level of anxiety, sense of presence, and reality judgement will also be explored. This paper presents the study protocol.

METHODS

This study is a three-armed feasibility pilot study with the following conditions: NO-FEAR Airlines with navigable images, NO-FEAR Airlines with still images, and a waiting list group. A minimum of 60 participants will be recruited. The intervention will have a maximum duration of 6 weeks. Measurements will be taken at four different moments: baseline, post-intervention, and two follow-ups (3- and 12-month). Participants' opinions, preference, satisfaction and acceptance regarding the images used in the exposure scenarios will be assessed. FP symptomatology outcomes will also be considered for secondary analyses. The anxiety, sense of presence, and reality judgement in the exposure scenarios will also be analysed.

DISCUSSION

This study will conduct a pilot study on the feasibility of an ICBT for FP and it is the first one to explore the evaluation of patients of the two type of images (still and navigable) and the role of presence and reality judgement in exposure scenarios delivered through the Internet. Research in this field can have an impact on the way these scenarios are designed and developed, as well as helping to explore whether they have any effect on adherence.

TRIAL REGISTRATION

NCT03900559. Trial Registration date 3 April 2019, retrospectively registered.

Pediatric Prevention: Oral Health Care

Children who have a dental home are more likely to receive preventative care, require fewer dental treatments, and are less likely to have dental disease. Many children demonstrate behavior management concerns that may impede families from establishing a dental home for their children. Conceptually, behavior concerns develop through a process of conditioning. Prevention of such problems should focus on providing positive experiences related to dental care. Treatment components to address behavior management concerns include graduated exposure, contingent reinforcement, modeling and prompting, distraction/relaxation, and cognitive behavior therapy. Further support, training, and reimbursement for time required to administer such treatment is needed.

Examining the Usage, User Experience, and Perceived Impact of an Internet-Based Cognitive Behavioral Therapy Program for Adolescents With Anxiety: Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) increases treatment access for adolescents with anxiety; however, completion rates of iCBT programs are typically low. Understanding adolescents' experiences with iCBT, what program features and changes in anxiety (minimal clinically important difference [MCID]) are important to them, may help explain and improve iCBT program use and impact.

OBJECTIVE

Within a randomized controlled trial comparing a six-session iCBT program for adolescent anxiety, Being Real, Easing Anxiety: Tools Helping Electronically (Breathe), with anxiety-based resource webpages, we aimed to (1) describe intervention use among adolescents allocated to Breathe or webpages and those who completed postintervention assessments (Breathe or webpage respondents); (2) describe and compare user experiences between groups; and (3) calculate an MCID for anxiety and explore relationships between iCBT use, experiences, and treatment response among Breathe respondents.

METHODS

Enrolled adolescents with self-reported anxiety, aged 13 to 19 years, were randomly allocated to Breathe or webpages. Self-reported demographics and anxiety symptoms (Multidimensional Anxiety Scale for Children-2nd edition [MASC-2]) were collected preintervention. Automatically-captured Breathe or webpage use and self-reported symptoms and experiences (User Experience Questionnaire for Internet-based Interventions) were collected postintervention. Breathe respondents also reported their perceived change in anxiety (Global Rating of Change Scale [GRCS]) following program use. Descriptive statistics summarized usage and experience outcomes, and independent samples t tests and correlations examined relationships between them. The MCID was calculated using the mean MASC-2 change score among Breathe respondents reporting somewhat better anxiety on the GRCS.

RESULTS

Adolescents were mostly female (382/536, 71.3%), aged 16.6 years (SD 1.7), with very elevated anxiety (mean 92.2, SD 18.1). Intervention use was low for adolescents allocated to Breathe (mean 2.2 sessions, SD 2.3; n=258) or webpages (mean 2.1 visits, SD 2.7; n=278), but was higher for Breathe (median 6.0, range 1-6; 81/258) and webpage respondents (median 2.0, range 1-9; 148/278). Total user experience was significantly more positive for Breathe than webpage respondents (P<.001). Breathe respondents reported program design and delivery factors that may have challenged (eg, time constraints and program support) or facilitated (eg, demonstration videos, self-management activities) program use. The MCID was a mean MASC-2 change score of 13.8 (SD 18.1). Using the MCID, a positive treatment response was generated for 43% (35/81) of Breathe respondents. Treatment response was not correlated with respondents' experiences or use of Breathe (P=.32 to P=.88).

CONCLUSIONS

Respondents reported positive experiences and changes in their anxiety with Breathe; however, their reports were not correlated with program use. Breathe respondents identified program design and delivery factors that help explain their experiences and use of iCBT and inform program improvements. Future studies can apply our measures to compare user experiences between internet-based interventions, interpret treatment outcomes and improve treatment decision making for adolescents with anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02970734 https://clinicaltrials.gov/ct2/show/NCT02970734.

Psychological Treatment for Depressive Disorder

Depression is highly prevalent and causes unnecessary human suffering and economic loss. Therefore, its treatment and prevention are of utmost importance. There are several advantages of using psychotherapy either by itself or combined with pharmacological treatment methods in the treatment of depression. First, it is well known that combining biological treatment with psychosocial methods increases the chances of recovery. Second, in some individuals, psychotherapy continues to be the only solution. Third, the use of antidepressants contains some safety risks and side effects, but psychotherapy does not. Fourth, clinically, depressive patients prefer psychotherapy to drug therapy. Use of a depression-focused psychotherapy alone is recommended as an initial treatment choice for patients with mild to moderate depression, with clinical evidence supporting the use of cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), psychodynamic psychotherapy (PDP), and problem-solving therapy (PST) in individual and group formats. Important developments took place within the past 20 years in the psychotherapy of depression. In the present chapter, we introduced several key issues, such as, Are all psychotherapies equally effective? Who benefits from psychotherapies? Is telepsychotherapy effective? Finally, we introduce the psychotherapy for special populations.

Potential Reduction of Symptoms With the Use of Persuasive Systems Design Features in Internet-Based Cognitive Behavioral Therapy Programs for Children and Adolescents With Anxiety: A Realist Synthesis

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) for children and adolescents is a persuasive system that combines 3 major components to therapy-therapeutic content, technological features, and interactions between the user and program-intended to reduce users' anxiety symptoms. Several reviews report the effectiveness of iCBT; however, iCBT design and delivery components differ widely across programs, which raise important questions about how iCBT effects are produced and can be optimized.

OBJECTIVE

The objective of this study was to review and synthesize the iCBT literature using a realist approach with a persuasive systems perspective to (1) document the design and delivery components of iCBT and (2) generate hypotheses as to how these components may explain changes in anxiety symptoms after completing iCBT.

METHODS

A multi-strategy search identified published and gray literature on iCBT for child and adolescent anxiety up until June 2019. Documents that met our prespecified inclusion criteria were appraised for relevance and methodological rigor. Data extraction was guided by the persuasive systems design (PSD) model. The model describes 28 technological design features, organized into 4 categories that help users meet their health goals: primary task support, dialogue support, system credibility support, and social support. We generated initial hypotheses for how PSD (mechanisms) and program delivery (context of use) features were linked to symptom changes (outcomes) across iCBT programs using realist and meta-ethnographic techniques. These hypothesized context-mechanism-outcome configurations were refined during analysis using evidence from the literature to improve their explanatory value.

RESULTS

A total of 63 documents detailing 15 iCBT programs were included. A total of six iCBT programs were rated high for relevance, and most studies were of moderate-to-high methodological rigor. A total of 11 context-mechanism-outcome configurations (final hypotheses) were generated. Configurations primarily comprised PSD features from the primary task and dialogue support categories. Several key PSD features (eg, self-monitoring, simulation, social role, similarity, social learning, and rehearsal) were consistently reported in programs shown to reduce anxiety; many features were employed simultaneously, suggesting synergy when grouped. We also hypothesized the function of PSD features in generating iCBT impacts. Adjunct support was identified as an important aspect of context that may have complemented certain PSD features in reducing users' anxiety.

CONCLUSIONS

This synthesis generated context-mechanism-outcome configurations (hypotheses) about the potential function, combination, and impact of iCBT program components thought to support desired program effects. We suggest that, when delivered with adjunct support, PSD features may contribute to reduced anxiety for child and adolescent users. Formal testing of the 11 configurations is required to confirm their impact on anxiety-based outcomes. From this we encourage a systematic and deliberate approach to iCBT design and evaluation to increase the pool of evidence-based interventions available to prevent and treat children and adolescents with anxiety.

Demystifying behaviour and dental anxiety in schoolchildren during endodontic treatment for primary teeth-controlled clinical trial

BACKGROUND

Behaviour and anxiety of children are predictors of effective dental treatment.

AIM

Compare the behaviour and anxiety during preventive care, endodontic treatment, and dental extraction.

DESIGN

Controlled clinical trial was conducted with 99 children aged 6-9 years. The children were distributed among three groups: G1 (control)-prophylaxis and topical fluoride; G2 (intervention)-endodontic treatment; and G3 (intervention)-tooth extraction. Behaviour was measured using the Frankl scale. Dental anxiety was assessed using the modified Venham Picture Test and measured at three moments: before, during, and after the procedure. Caregivers answered a questionnaire addressing the child's previous dental experience. Clinical examinations were performed by a calibrated examiner (Kappa > 0.70) for the identification of dental caries (d-dmft/D-DMFT). Statistical analysis involved repeated-measures Poisson regression, with level of significance was P < 0.05.

RESULTS

Neither negative behaviour nor anxiety was associated with the type of procedure. Negative behaviour was associated with the need for restraint during a previous dental appointment (P = 0.012). Dental anxiety was associated with age (P = 0.037), previous difficult behaviour (P < 0.001), moment of measurement (P < 0.001), and dental caries on permanent teeth (P = 0.001).

CONCLUSIONS

Negative behaviour and dental anxiety in children were not associated with the type of treatment performed.

Are Technology-Based Interventions Effective in Reducing Dental Anxiety in Children and Adults? A Systematic Review

OBJECTIVES

The aim of this study was to evaluate the effectiveness of technology-based interventions for the treatment of dental anxiety in children and adults.

DATA SOURCES

A systematic search using relevant keywords was conducted in PubMed-Medline, EMBASE, PsycINFO, CINAHL, Scopus, and The Cochrane Library.

INCLUSION CRITERIA

Randomized controlled trials (RCTs) that compared technology-based interventions with inactive controls in the treatment of moderate to severe dental anxiety were included.

RESULTS

A total of seven RCTs were included in the review. These studies investigated the effectiveness of video modeling, computerized cognitive behavioral therapy, virtual reality exposure therapy, and distraction with music and audiovisual video material. Six studies examining video modeling, computerized cognitive behavioral therapy, virtual reality exposure therapy, and distraction (audiovisual) showed significantly greater reductions in dental anxiety than inactive controls in both children and adults. None of the included studies followed Consolidated Standards of Reporting Trials guidelines completely or reported sufficient data, thereby precluding a possible meta-analysis. Four out of seven included studies were assessed to be at high risk of bias.

CONCLUSIONS

A limited number of studies supported the effectiveness of technology-based interventions in the treatment of dental anxiety in children and adults.

CLINICAL SIGNIFICANCE

The quality of the methods of studies on the effects of technology-based interventions allows only limited inferences on the effects of these interventions. However, within the limitations of the systematic review, the results converge to suggest that technology-based interventions may be useful as an adjunct to standard dental care. High-quality RCTs are needed to determine the (relative) effectiveness of these interventions.

PROSPERO REGISTRATION NUMBER

CRD42017064810.

The effectiveness of Cognitive Behavioural Therapy in the reduction of dental anxiety in children

Data sourcesCochrane Library, Embase, PubMed, Scopus, Web of Science, LILACS/BBO, PsycINFO, ClinicalTrials, ISRCTN registry, UK National Institute for Health and Care Excellence, International Clinical Trials Registry Platform, ProQuest and OpenGrey.Study selectionTwo independent and calibrated reviewers selected randomised controlled trials investigating cognitive behavioural therapy use in dentally anxious children.Data extraction and synthesisRisk of bias was assessed by two independent reviewers according to the Cochrane Collaboration tool. Clinical and methodological heterogeneity were assessed to determine whether a meta-analysis could be performed but the data were not similar enough and therefore a narrative synthesis is provided.ResultsSix studies were included, all written in English between 1980 and 2017. Two were completed in the United States, one in Jamaica, one in Iran, one in Sweden and one in Norway and included 269 patients in total ranging from 41 months to 18 years. Two studies had high risk of bias. In five studies, CBT patients showed significantly reduced levels of anxiety. In three studies improvement was observed in cooperation/behaviour. In two studies, avoidance behaviours improved.ConclusionsCBT has been shown in published literature to have a positive effect on childrens anxiety and co-operation; however the quality of evidence for this is low. There is no current consensus on which outcome measure/s should be used, which prevents meta-analysis of results. Further randomised controlled studies are required, ideally using the same outcome measures, to develop evidence based guidance on the use of CBT in dentally anxious children.

[Quality criteria of internet-based cognitive-behavioral interventions for children and adolescents and their parents - A systematic review]

Quality criteria of internet-based cognitive-behavioral interventions for children and adolescents and their parents - A systematic review Abstract. Introduction: This study provides an overview of existing internet-based evidence-based cognitive behavioral interventions (iCBT) for children/adolescents and their parents. The studies were evaluated based on preliminary defined quality criteria regarding their usability in the healthcare system. Methods: The review was performed according to PRISMA guidelines and evaluated the scientific literature concerning to iCBT. We conducted a comprehensive literature search of PubMed, PsychINFO, PsychARTICLES, PsychNDEX and Science Direct using relevant keywords. Studies were rated according to 10 previously predefined quality measures. Results: A total of 4,479 articles were screened, 62 of which were selected for further analysis. Thereof, 24 international iCBT programs with 50 randomized controlled trials (RCTs) were evaluated and met the quality criteria (M = 7.25, SD = 1.07). Further 13 publications showed preliminary efficacy for another 11 international iCBT programs and met the quality criteria (M = 7.45, SD = .82). There was no significant difference between programs evaluated within and without RCTs t(33) = -.56, p = .58. Conclusions: Our results indicate that multiple international iCBT programs exist. Because in Germany the waiting time for psychotherapeutic or psychiatric treatment is still about five months, iCBT programs have the potential to reduce this gap.