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Influence of adapted environment on the anxiety of medically treated children with developmental disability

Influence of Adapted Environment on the Anxiety of Medically Treated
Children with Developmental Disability
To examine the influence of a sensory adapted environment (SAE) on the behavior and arousal levels of children
with developmental disability in comparison with typical children, during a stress-provoking medical situation.
Study design
Sixteen children (6-11 years old) with developmental disability and 19 age-matched typical children partic-
ipated in a cross-over trial measuring behavioral and psychophysiological variables, performed during a dental intervention.
Both groups performed better in the SAE compared with the regular environment (RE), by comparing: the mean
duration of anxious behaviors in the SAE and RE (5.26 and 13.56 minutes; P < .001); the mean electrodermal activity for
arousal levels, before commencement of treatment in the SAE and RE (784 and 349 Kohms; P
؍ .002); and the mean
electrodermal activity during treatment in the SAE and RE (830 and 588 Kohms; P
؍ .001). A significant group by
environment interaction was revealed, indicating that the difference in the 2 environments was greater in children with
developmental disability than typical children in all 3 measures.

These findings indicate the importance of environment in determining the comfort level of all children. The
greater difference in the 2 environments observed in children with developmental disability suggests that this group benefits
more from sensory adapted environments. (J Pediatr 2008;xx:xxx)

health care Potential anxiety-provoking medical events include local and general anesthetics, preoperativesurgical preparation (induction of anesthesia), radiological procedures, suturing of wounds, oncology therapy, neuro- logical examination, and many Modes of management that have been described include: conscious sedation,stress-reducing medical devices, behavioral relaxation, pharmacologic analgesic and sedative interventions, hypnosis, andThis study addresses the option that modes of treatment in these situations could also include the sensory adaptationof clinical environments.
Participation is defined as involvement in life situations, and represents the highest level of functional The International Classification of Functioning and Health stresses the importance of iden-tifying risk factors that may affect a child’s participation in life It may beinfluenced by personal (predisposition of the individual) or environmental (the physicalsetting) People with developmental disabilities have substantial functional lim-itations that significantly impede their participation in daily However, From the Issie Shapiro Educational Centre, although the functional limitations of subjects with developmental disability frequently Raanana, Israel (M.S.); School of Occupa-tional Therapy, Faculty of Medicine, He- captures the most attention, the enhanced intolerance of environmental stimuli not brew University, Hadassah, Jerusalem, Israel normally or unusually disturbing to others should also receive attention.
(M.S., S.P.); Department of CommunityDentistry, Faculty of Dental Medicine, He- A study of typical children demonstrated that behavioral correlates and psycho- brew University, Hadassah, Jerusalem, Israel physiological measures of the autonomic sympathetic nervous system improved signifi- (H.S.-C.); Department of Medicine, Facultyof Medicine, Hebrew University, Hadassah, cantly in a sensory adapted environment The latter consists of a designated room partially lit, with controlled multi-sensory stimuli. SAE has been proposed to improve the The authors declare no potential conflicts quality of life of varied populations sustaining anxiety, pain, and unrest, including individuals with developmental disability, Alzheimer’s disease, or traumatic brain inj- Submitted for publication Mar 27, 2008;last revision received Aug 1, 2008; ac- The physical environment includes special lighting effects, relaxing music, vibration, and aromas. Research documenting the outcome of the multi-sensory environ- Reprint requests: Michele Shapiro, OT,MSc, PO Box 29, Raanana, 43100, Israel.
ment reports reduction of pain, behavior facilitation, and dental hygienist, including manual dental calculus removal balance of heart rate (reduction of heart rate in hyperactive and tooth cleaning with a low-speed dental hand-piece and a children and increase of heart rate in passive rotary bristle brush. No local anesthesia or sedation was used.
Evaluation of autonomic sympathetic activity by assessing an The dental hygienist was instructed to provide regular uni- individual’s palmar electrodermal activity (EDA) is recognized as form treatment to all children, regardless of the environment.
This study examines the influence of SAE, during a Environments
stressful situation, on children with developmental disability SENSORY ADAPTED ENVIRONMENT. The SAE included visual
and compares their responses with those of typical children.
sensation: 1) No overhead fluorescent lighting (50 Hz) or Dental clinics are usually characterized by noises, odors, dental overhead lamp; 2) Adapted lighting consisted of bright lights, intrusive contact, and anticipation of pain. The dimmed upward fluorescent lighting (30-40 000 Hz), slow altered neurophysiological predisposition of individuals with moving, repetitive visual color effects (“Solar Projector”, developmental disability with the common dental clinic en- Rompa Co., Chesterfield, UK); and 3) The dental hygienist vironment makes a dental visit a particularly uncomfortable wore a head mounted LED lamp (Black Diamond Zenix IQ, experience. Therefore this setting served as a suitable model Salt Lake City, Utah) directed into the patient’s mouth.
in that the essential elements aforementioned may be easily Auditory and somato-sensory stimuli were also included controlled. We hypothesized that children with developmen- in SAE. Rhythmic music via loudspeakers (Dan Gibson’s tal disability would find dental treatment a more stressful Solitudes: Exploring Nature with Music) at 75 db level with situation than typical children and that the children with bass vibrator for soma-sensory stimulation (Aura, Bass developmental disability would be more positively influenced Shaker, model AST-1B, 4 OHMS; Unical Enterprises, City by SAE. This would be observed by duration of negative of Industry, California), connected to the dental chair pro- behaviors and electrodermal activity before and during pro- Tactile stimulus was also included in SAE. For children with developmental disability (and not for typical children), a “friendly butterfly” papoose “hugged” the child tightly. Fortypical children, a dental radiography vest was placed on the Patients
child (providing a deep “hugging” effect). The Helsinki per- Estimation of sample size was based on published data mission was granted for use of the “friendly butterfly” only for that used a design similar to Accordingly, a required children with special needs because this has a restrictive sample size of 32 was calculated, including 16 children with function and should not be used for typical children. This was developmental disability and 16 typical children. To ensure supported by parent approval. The rationale for use of the that this study was adequately powered and to reduce the risk physical restraint on patients with developmental disability is of type II error, the number of children was increased beyond to reduce preemptively possible disruptive movements rather the suggested number to 40 (20 children for each group).
than rely on deeper sedation or general anesthetic to contain However, only 19 children with developmental disability could be recruited from the Beit Issie Shapiro Center, Israel,which offers educational and therapeutic services for children REGULAR ENVIRONMENT. Fluorescent lighting (50 Hz) and
with developmental disability and is also the location of a overhead dental lamp were used in the RE. The papoose special-needs dental clinic. Each child who is accepted into “hugged” the developmental disability child less tightly, only the Issie Shapiro Center has received a diagnosis. Similar to ensure safety. The radiography vest was not supplied for numbers of typical children (matched for age and sex) were recruited (children of employees at the same center). Of the19 children with developmental disability, 3 were disqualified because they were found to have a developmental disability The Negative Dental Behaviors Checklist (NDBC) and autism. Thus, 16 children with developmental disability was developed by the research team. Content inter-rater and 19 typical children (with no known disabilities) were reliability was determined after training 2 independent coders (not researchers participating in this study) and The 16 participants (11 male and 5 female) with devel- yielded a standardized alpha value of 0.93. The NDBC opmental disability were aged from 6 to 11 years (mean, 8.3 contains 7 behavioral descriptors: movements of head, years; SD, 1.3) and had moderate to severe Nine- forehead, eyes, and mouth, coughing/gagging, crying/ teen children were developmentally typical (13 male and 6 screaming, and other. All behaviors were recorded with female) and aged from 6 to 11 years (mean, 8 years; SD, 1.74).
videotape. Duration of negative behaviors in minutes was The study was approved by the Ethics Committee on Human measured by the coder with a stopwatch. The NDBC is Experimentation of the Tel Aviv University. Parental in- formed consent was granted in writing. The procedure used EDA was monitored by changes in palmar skin con- was a routine dental prophylactic cleaning performed by a ductance by means of electrodes (Mindlife Co, Jerusalem, ARTICLE IN PRESS
Table. The effect of sensory adapted environment compared with the regular environment on typical
children and children with developmental disability, according to behavioral (negative dental behavior
checklist) and physiological (electrodermal activity) measures

Child Population
P* value
Duration of accumulative anxious behaviors by NDBC Duration of accumulative anxious behaviors by NDBC Tonic EDA before commencement of dental treatment Tonic EDA before commencement of dental treatment Phasic EDA during dental treatment *P levels according to analysis of variance.
Israel). The EDA was determined with an increase in Kohms this study, we adopted a cross-over design that enabled con- reflecting raised skin resistance (the higher the score, the trol of each subject and thereby controlled for any potential more relaxed) and decreased Kohms caused by enhanced heterogeneity of the All tests applied were 2-tailed, perspiration (the lower the score, the less relaxed).
and a P value Ͻ.05 was considered to be statistically signifi-cant.
Study Design
The study used a random cross-over design. During phase 1, the children with developmental disability were as- In all analyses, the treatment sequence effect (time 1 sessed. Eight patients with developmental disability were ini- versus time 2) was found not to be significant. Therfore we tially treated with SAE (time 1) and received RE on the deduced that there was no cross-over effect and the indepen- second encounter (time 2; group A, n ϭ 8). For the second dent treatment environment effect could be independently group of 8 children with developmental disability (group B,N ϭ 8), the procedure was reversed. The children received dental treatment approximately 20 to 25 minutes per session,in each dental environment, with a period of 4 months The Duration of Anxious Behaviors by NDBC
between the 2 sessions. After the study of the children withdevelopmental disability, the typical children underwent a Significant main effects of environment and of group similar cross-over study in 2 groups.
were revealed on duration of anxious behaviors (analysis EDA was measured before (tonic) and during (phasic) [2X2], F[1,33] ϭ 29.09, P Ͻ .001, ϭ 0.46; F[1,33] ϭ the dental procedure. During the treatments, each child was 20.82, P Ͻ .001, Etaϭ 0.38). In addition, a significant filmed, and 1 of the coders coded all behaviors and measured group by environment interaction was found (F[1,33] ϭ the duration of anxious behaviors with the NDBC.
15.63, P Ͻ .001, ϭ 0.32). The presents the meansof the 2 groups in both environments.
Data Analysis
As shown in the the main effect was a shorter duration of anxious behaviors in the adapted environment SAS computer software (SAS Institution, Cary, North (mean, 5.26; SD, 7.9) as compared with the regular environ- Carolina) was used to analyze the scores in the study. Analysisof variance was applied to compare SAE and RE for behaviors ment (mean, 13.56; SD, 11.6). Regardless of environment, and EDA, with repeated measures for environments and the 16 children with developmental disability had an overall treatment sequence (time 1 versus time 2). In addition, to longer duration of anxious behaviors (mean, 16.24; SD, 8.8) relate to potential heterogeneity of variance, non-parametric than the 19 typical children (mean, 2.59; SD, 8.8). As indi- analysis (Mann-Whitney and Wilcoxon for repeated mea- cated by the interaction effect, the difference in the 2 envi- ronments in the children with developmental disability is Interactions among the developmental disability group greater than in the typical children. According to simple effect and typical group, the 2 environments (SAE and RE), and the analysis that was applied to assess the source of the interac- treatment sequence in the effect on behavior and EDA was tion, a significant difference was found in the 2 environments tested with a simple effect analysis. This analysis explores the for the typical group (F[1,18] ϭ 9.13, P Ͻ .01, ϭ 0.34) nature of the interaction by examining the difference in and for the developmental disability group (F[1,15] ϭ 19.62, groups within 1 level of 1 of the independent In Influence of Adapted Environment on the Anxiety of Medically Treated Children with Developmental Disability ARTICLE IN PRESS
Electrodermal Activity
therefore only data related to analysis of variance were pre- TONIC EDA (BASELINE) BEFORE COMMENCEMENT OF DENTAL
TREATMENT. Data revealed significant main effects of envi-
ronment and group on baseline tonic EDA (analysis of vari-
ance [2X2], F[1,33] ϭ 11.61, P ϭ .002, ϭ 0.26; F[1,33] ϭ This study confirms that the SAE creates a significant 11.00, P ϭ .002, ϭ .25). In addition a significant group calming effect for both children with developmental disability by environment interaction was found (F[1,33] ϭ 5.67, P Ͻ and typical children undergoing a high anxiety procedure. In .023, ϭ 0.15]. The presents the means of the 2 interviews with parents, it was clear that 63% of children with developmental disability exhibit more than average general As shown in the the main effect on tonic EDA anxiety, as compared with 38% of the typical children. Al- before treatment in the adapted environment (mean, 784.41; though both groups of children were significantly more re- SD, 724.1) was higher (more relaxed) as compared with the laxed during dental care in the SAE, the results of this regular environment (mean, 349.43; SD, 318.3). Regardless research indicate that children with developmental disability of environment, the 16 children with developmental disability relaxed to a greater extent than did the children with typical had an overall higher (more relaxed) tonic EDA before com- development. This was objectively demonstrated by both be- mencement of treatment (mean, 798.37; SD, 411.2) than the havioral and physiological measures. Our data support the 19 typical children (mean, 335.47; SD, 411). As indicated findings of Hall and that the use of various by the interaction effect, the difference in the 2 environments sensory strategies may be effective in reducing many behaviors in the children with developmental disability is greater than in associated with sensory processing disorders.
the typical children. According to simple effect analysis that The study is consistent with earlier observations of was applied to assess the source of the interaction, a signifi- participation and environment. According to peo- cant difference was found in reactions to the different envi- ple with developmental disability, similarly to people with ronments for the typical group (F[1,18] ϭ 4.97, P Ͻ .05, autism, are strongly influenced by the physical environment.
ϭ 0.22) and for the developmental disability group This is because sensory processing disorders are pervasive in (F[1,15] ϭ 7.49, P Ͻ .05, ϭ 0.33).
the developmental disability group, expressing theselves as aninability to filter out distracting stimuli in the environment. It is this sensory flooding that leads to emotional discomfort HASIC EDA DURING TREATMENT. Data revealed significant
main effects of environment and group during treatment manifesting as high anxiety levels and difficulty in participa- (analysis of variance [2X2], F[1,33] ϭ 23.96, P ϭ .001, For this reason, when offering children with develop- ϭ 0.42; F[1,33] ϭ 14.20, P ϭ .001, Etaϭ 0.30] on phasic mental disability an environment in which aversive stimuli EDA. In addition, a significant group-by-environment inter- were substituted by gentler stimuli, like soft moving light action was found (F[1,33] ϭ 10.66, P Ͻ .003, ϭ 0.24).
effects, calming music, and deep pressure, the children be-came more focused on the pleasant stimuli and their anxiety The presents the means of the 2 groups in both envi- was reduced. The modified sensory environment results in the participants’ attention being intently focused on the moving The main effect on phasic EDA during treatment in the visual and auditory stimuli or the deep pressure, bringing adapted environment (mean, 830.59; SD, 588.6) was higher about an “altered state,” with the inevitable concomitant re- (more relaxed) as compared with the regular environment duced awareness of discomforting or noxious stimuli, much as (mean, 359.87; SD. 326.6). Regardless of dental environ- an altered state may reduce the intensity of pain in chronic ment, the 16 children with developmental disability had an overall higher (more relaxed) phasic EDA during treatment Children with developmental disability, in both envi- (mean, 838.43; SD, 380.4) than the 19 typical children ronments, familiar with the location, may have started their (mean, 352.02; SD, 380.4). As indicated by the interaction treatment in a more relaxed manner. Typical children, unfa- effect, the difference in the 2 environments in the children miliar with this center for the developmentally disabled, may with developmental disability is greater than in the typical have been more influenced by preconceived associations and children. According to simple effect analysis that was applied earlier experiences. Typical children may be buffered from to assess the source of the interaction, a significant difference sensory stimuli in some way and accordingly independent of was found in the 2 environments for the typical group environmental and therefore may not have been (F[1,18] ϭ 8.68, P Ͻ .01, ϭ 0.33) and for the devel- influenced by the regular or adapted stimuli to the same opmental disability group (F[1,15] ϭ 15.34, P Ͻ .01, Etaϭ extent. Elucidation of the neural mechanisms mediating these differences, including cortisol measures, presents a worth- Because of the wide heterogeneity of variance as seen in while investigative challenge for future studies.
the non-parametric analysis, Mann-Whitney, and also In subjects with developmental disability and typical Wilcoxon for repeated measures were carried out between the subjects, to modulate conditions of the physical environment groups for all the analysis of variance analyses. Levels of to optimize participation, it may be necessary to find some significance remained the same as those for the analyses, and means of individualizing sensory inputs. This may be achieved ARTICLE IN PRESS
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Influence of Adapted Environment on the Anxiety of Medically Treated Children with Developmental Disability


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