Dental Anxiety In Children Research Articles

The Effect of Three-point Acupressure Therapy on Anxiety Levels in Children Undergoing Dental Procedures.

To evaluate the efficacy of three-point acupressure therapy in decreasing the dental anxiety in children undergoing dental procedures and to introduce acupressure as a simple, noninvasive, and cost-effective technique of reducing dental anxiety in children. One hundred and sixty-eight, 8-12 years participants who met the inclusion criteria were randomly allotted to either group I (three-point acupressure) (n = 84) or group II (control) (n = 84). All children were subjected to a self-report measure of anxiety [Modified Child Dental Anxiety Scale (MCDAS)] 30 minutes before starting and after completing the dental treatment. For group I children, acupressure beads were applied on selected three acupoints for approximately 10 minutes and were left adhered in place. After 20 minutes, anxiety scores were recorded for all the children and allotted treatment procedure was initiated. For group II children, the same methodology was followed except for the application of acupressure beads. Frankl behavior (FB) rating scale, pulse rate (PR), and systemic saturation levels of oxygen were also recorded as secondary outcome measures. The data obtained was analyzed statistically using Chi-squared analysis, t-test, repeated measures analysis of variance (ANOVA) along with post hoc Bonferroni test. Significance level was predetermined at p ≤ 0.05. At time frame (TF)-2, significant decrease in anxiety scores was observed in acupressure group irrespective of the treatment procedure, whereas in control group, it increased significantly. PR was also increased in acupressure group and FB scale was improved. In control group, PR increased and behavior was not improved. Between TF-2 and 3, no reduction in anxiety score was observed. The three-point acupressure therapy reduces anxiety in children undergoing dental procedures when compared to nonacupressure group and the difference was statistically significant. Acupressure is a noninvasive stimulation technique applied to acupoints and can be easily administered by a trained pediatric dentist. Sisodia M, Kaur H, Garg N, et al. The Effect of Three-point Acupressure Therapy on Anxiety Levels in Children Undergoing Dental Procedures. Int J Clin Pediatr Dent 2024;17(2):136-142.

Comparison Between Jacobson’s Progressive Muscle Relaxation Technique and Audio-Visual Distraction Technique in Comparison to Tell-Show-Do Technique in Reducing Dental Anxiety in Children During Dental Visit: A Randomized Clinical Trial

Comparison Between Jacobson’s Progressive Muscle Relaxation Technique and Audio-Visual Distraction Technique in Comparison to Tell-Show-Do Technique in Reducing Dental Anxiety in Children During Dental Visit: A Randomized Clinical Trial

Scentsational Smiles: The Impact of Aromatherapy on Alleviating Dental Anxiety in Children

Scentsational Smiles: The Impact of Aromatherapy on Alleviating Dental Anxiety in Children

Comparison of Automatically Controlled Injection System with a Traditional. Syringe for Multiple Infiltrations in Children Aged 6-12 Years: A Randomized Controlled Trial.

Children's conduct is significantly impacted by pain during dental procedures. Children's pain and discomfort can be reduced using computer-controlled local anesthetic delivery, which applies a steady, gradual flow of the anesthetic solution into the tissues. Using a self-report anxiety scale, the study aimed to assess and compare children's perceptions of discomfort following a new auto-controlled injection method to a traditional local anesthetic procedure. A total of 25 children, ages 6-12 requiring the use of local anesthesia for treatment on both sides of the arch were selected. It was a split-mouth design, in which each participating child received both types of infiltrations in two separate, consecutive visits, using a metallic syringe in one session, and using the I-Ject device in the other. Before administering anesthesia, all the children's anxiety scales were recorded using the Modified Child Dental Anxiety Faces Scale simplified to assess the anxiety level of a child. In the first appointment, Conventional anesthetic technique was and in the second appointment anesthesia was delivered using a computer-controlled device. Faces pain scaleRevised, a selfreport measure of pain was recorded immediately after completion of both types of local anesthesia (LA) administration. Patients reported greater comfort with the I-Ject computer-controlled device than with conventional anesthesia. Together with the practitioner, the computer system produced a pleasant and cozy environment for the youngster.

Comparative Evaluation of the Effectiveness of Innovative Periorbital Eye Massager and Virtual Reality Eyeglasses for Reducing Dental Anxiety during Dental Restorative Procedures in Children.

Many behavior management techniques are employed to reduce the anxiety associated with dental procedures in children. One of the most commonly used methods comprises audiovisual distraction using virtual reality (VR) eyeglasses. In this study, an innovative device, a periorbital eye massager (PEM), is compared with VR to evaluate dental anxiety in children. in this study, 22 children were divided into two groups, that is, group I consisting of PEM and group II consisting of VR. The participants were instructed to wear the device and then subjected to dental restorative procedures. After completion of the procedure, anxiety was measured using a validated questionnaire by the children and by using the modified behavior pain scale by the second investigator. Also, physiological parameters like heart rate and oxygen saturation were evaluated before and after a dental procedure. The results were statistically insignificant for group I and group II when a validated questionnaire and modified behavior pain scale were used to measure the dental anxiety of children. Also, the data also shows no significant difference in heart rate and oxygen saturation between the two groups. The innovative PEM can also be used as an effective behavior management tool in managing dental anxiety in children, as there was no statistically significant difference between PEM and VR. As a pediatric dentist, the methods for administering a patient present a novel challenge because behavior management varies from patient to patient. As a result, the prospects for augmenting various techniques of behavior therapy for pediatric patients are limitless. Gala UP, Kalaskar R. Comparative Evaluation of the Effectiveness of Innovative Periorbital Eye Massager and Virtual Reality Eyeglasses for Reducing Dental Anxiety during Dental Restorative Procedures in Children. Int J Clin Pediatr Dent 2024;17(1):48-53.

Caries risk and dental anxiety in recall patients in a specialised paedodontic university clinic

Objective To evaluate parental reports of the oral health status and anxiety levels of children who attended a paediatric dental service and their association with children’s caries experience. Methods This questionnaire- and dental record-based study included a total of 70 healthy recall children aged between five and 10 years, who presented for a dental check-up to the specialised paedodontics department at the University of Greifswald, and for whom an application of fluoride varnish was indicated. The accompanying parent (n=70) was asked to evaluate their child’s dental anxiety (dichotomously with a single question – yes or no answer) and oral health status (good, satisfying, poor). Caries experience was categorised according to the dmft index based on World Health Organisation (WHO) criteria. Results An overall frequency of dental anxiety of 40% (n=28) was found in recall children according to parental report. Only 32.1% (n=9) of those were children with low to very low caries experience, whereas 67.9% (n=19) belonged to the moderate to high/very high caries experience group. Thus, dental anxiety in this study was significantly associated with caries experience based on dmft index (p=0.030, chi-square test). Parental assessment of the oral health status of the schoolchildren and their caries experience level also showed a statistically significant association (p=0.020; chi-square test). Conclusion: Dental anxiety in recall children attending a specialised paediatric university dental clinic is high, which is clearly associated with higher caries experience. The majority of children who attended for dental follow-up appointment had moderate to very high caries experience, which was also associated with higher parent-reported dental anxiety and a poorer oral health status report.

Family's socioeconomic and demographic factors on elements of children's dental and oral health: A scoping review.

Family plays a significant role in children's dental and oral health (DOH) elements, such as children's DOH knowledge and practice, the development of children's dental fear and anxiety (DFA), children's dental visits, and children's DOH status. The study aims to address the interrelationship of these elements based on individual and familial socioeconomic and demographic (SED) attributes. Given the possibility that the COVID-19 epidemic might alter oral health and disrupt dental care, a systematic literature search from the Scopus and Web of Science library database was limited to the 2017-2019 peer-reviewed published literature, which includes quantitative studies that investigated at whether SED status contributed to children's DOH elements. Four sets of keywords are combined in both library database literature searches. Using the PRISMA-ScR Checklist as a reference, we conduct this scoping review. A total of 15 studies were included. Studies were from Brazil, Iran, China, India, Indonesia, Peru, Portugal, and UK. The socioeconomic characteristics include parental education, income, employment, assets and home ownership, type of residence, and health insurance coverage. The demographic characteristics include parent's age, children's age, the number of family members, and family type. There were 13 studies observing parent's education, seven examining family income, four identifying parental employment, three measuring family assets, six assessing the type of residence, and one recording health insurance coverage. Few studies assessed socioeconomic proxies such as school type, free school lunches, and social networks. In addition, race, the number of household members, the number of children, and family type were measured in at least one of the literature. Family SED characteristics may define a pathway to children's DOH elements.

Dentophobia in Children During the Covid-19 Pandemic

Dentophobia is a significant problem in oral health management. In the conditions of the COVID-19 pandemic, with the associated sanitary measures (quarantine, social distancing) at national level, the fear and dental anxiety are supposedly increased, especially in children. Pediatric patients are emotionally affected when they faced with the need for emergency dental intervention.
 The current study seeks to assess the emotional state of children aged 8-12, who needed dental care during quarantine, at the regional level, as well as the degree of anxiety of their parents. Dental anxiety was assessed independently by the dentist, parents and children themselves. If in children, the level of dental anxiety increased insignificantly, compared to the pre-pandemic period, the levels of parental anxiety were higher. The boys in the pandemic group had a higher level of anxiety, especially in the parental assessment.
 The results suggest that the reorganization of oral care in the pandemic scenario did not have a major effect on children's dental anxiety. However, the results of the assessment in boys show that they may be more vulnerable and need special care to alleviate their anxiety and reduce their risk of dentophobia in the future. These conclusions should be treated with caution, given the small sample size, which requires further confirmation. It is also important to convince parents of the safety of a visit to the dentist during a pandemic, to minimize their anxiety about their children's dental fears.

Short Term Effects of Inhalation Sedation on Child Dental Fear and Anxiety.

Dental procedures profoundly affect a child's dental fear and anxiety, rendering dental treatment difficult. Inhalation sedation with a mixture of nitrous oxide and oxygen (NO2/02) breathed through a nosepiece is a form of light conscious sedation widely used in apprehensive children to help them relax and accept dental treatment. This, however, can have both shortand long-term effects on child dental fear and anxiety. This study aimed to assess the short-term immediate effect of inhalation sedation on child dental fear and anxiety scores. This analytical cross-sectional study was conducted at the Department of Paediatric Dentistry at Rehman College of Dentistry, Peshawar, Pakistan, over a period of 1.9 years (January 2019- October 2020). A total of 171 children aged 6-11 years were selected with moderate to severe dental anxiety using the Child Fear Survey Schedule-Dental Subscale (CFSS-DS), requiring pulp therapy in at least one of their deciduous molars. Baseline anxiety scores were calculated using Venham Clinical Anxiety Score (VCAS) and Venham Picture test (VPT) with a dental check-up and fluoride application. VCAS and VPT scores were then assessed at the end of their scheduled second dental visit involving dental anaesthesia and inhalation sedation. VCAS and VPT scores at the end of treatment were compared with the baseline scores. Out of 171 children, 86 were male and 85 were female, with a mean age of 7.77. Females showed a higher range of VCAS and VPT scores (p ≤0.001) compared to males. The VCAS and VPT scores declined just at the end of the second dental visit following dental anaesthesia with inhalation sedation (mean difference = 1.96 and 3.39, respectively), which was statistically significant (p ≤0.001). Inhalation sedation has a significant role in reducing child dental fear and anxiety in the short term.

The effect of aromatherapy with Lavender-Neroli oil and music in management of pediatric dental anxiety: a randomized control trial

AimThis study aimed to evaluate the efficacy of aromatherapy with Lavender-Neroli essential oil combined with background music in reducing dental anxiety and pain during anesthesia in children.Materials and methodsA total of 56 children aged 6–10 years old who needed dental treatment with inferior alveolar nerve injection (IANB) were randomly divided into two groups: Group 1 (Experimental, n = 28) aromatherapy with music group, and Group 2 (Control, n = 28) the placebo group. Children in the group 1 were asked to inhale the aromatic blend of Lavender-Neroli essential oil using a nasal mask similar to one that is used for nitrous oxide after modifying it by adding a 3D printed box on its circle hole and listening to their favorite music as a background before 5 min and during anesthesia, meanwhile in the placebo group children were asked to wear an empty nasal mask. Anxiety and pain were been assessed before and after anesthesia using the self-report anxiety scale Facial image scale (FIS), Observational pain assessment scale Face-Legs-Activity-Cry-Consolability (FLACC), heart rate, SPO2 saturation, diastolic and systolic blood pressure.ResultsDental anxiety and vital signs except SPO2 saturation were significantly lower in the aromatherapy with music group when compared to the control group (p < 0.05), with no differences in pain perception between groups (p = 0.176).ConclusionsAromatherapy with Lavender-Neroli oil combined with music seems to be a useful and safe non-pharmacologic technique for managing dental anxiety in children.

Assessment of Dental Anxiety in Children: Reliability and Validity of the Questionnaire to Assess Dental Anxiety in Children (QADA-C).

This study presents a measure to assess dental anxiety in children. To gain a better understanding of children's fear and anxiety in the dental setting, instruments to gather data with high quality are necessary and missing, especially in the German language. Based upon the facet approach, the Questionnaire to Assess Dental Anxiety in Children (QADA-C) includes items concerning anxiety reactions in thinking, behavior, and feelings in the form of short statements. The item formulation was adapted for children of the target age (9-11 years), and items were presented with pictures of dental situations. Item and reliability analyses in a sample of 1019 children showed the good quality of the instrument (Cronbach's alpha = 0.89), and the validity indicators revealed its ability to differentiate high-anxiety, low-anxiety, and non-anxious children with an overall sum score. This score was proven to correlate with oral health criteria (decayed/missing/filled teeth, oral health behavior, oral health knowledge). Its easy administration and appropriateness for children make the questionnaire applicable in the dental office for clinical purposes as well as in research contexts.

Chromotherapy: a useful tool for managing anxiety in children

Background: Dental anxiety is a type of fear developed due to threatening stimuli. Assessing the child's level of dental anxiety is very important to successfully carry out many treatment procedures in dentistry. Needles in general can cause dental anxiety. Chromotherapy is an ancient alternative medicine practice that uses the energy of the visible spectrum of electromagnetic radiation (i.e., coloured light) to induce changes in the human body. The objective of this study was to clinically evaluate and compare the effect of chromotherapy on the level of anxiety in patients treated with infiltration under local anaesthesia. Methods: This is a randomized control trial where anxiety was assessed using heart rate and animated emoji scale (AES) in children aged 4-14 years requiring infiltration injection of local anaesthesia. Patients were divided into 4 groups: group-1 blue, group-2 pink and group-3 yellow, group 4-control. Evaluation of all parameters was carried out at three levels, i.e., pre-operative, post-chromotherapy session and infiltration after local anaesthesia. Results: This study demonstrated that patients subjected to blue, pink and yellow colour therapy had a statistically significant reduction in anxiety compared to the control group after chromotherapy. Conclusions: Chromotherapy plays an important role in managing dental anxiety in children and can be effectively incorporated into routine practice.

Prevalence of dental fear among students of Hyderabad Sindh.

Background: Despite the advancements in making dentistry more comfortable, dental phobia remains a significant concern. Research suggests that children's dental anxiety may persist into adolescence, leading to avoidance of dental care and disruptive behavior during treatment. Early identification of children with dental fear is crucial for dental professionals to promptly employ appropriate pediatric management strategies. The study aims to assess the prevalence of dental fear among students in Hyderabad, Pakistan. Methodology: A cross-sectional study was conducted among 11- to 16-year-old male and female students in schools in Hyderabad, Pakistan. The Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) in English was utilized. The study included students in grades 6 to 8 residing in Hyderabad, with no general pathology and not on any medication. Data analysis was performed using SPSS version 25. Results: The study encompassed 295 participants, 45.1% females and 54.9% males. The percentage of participants experiencing dental fear (combining moderate and high fear) was 168 (57%), while 127 (41%) reported no dental fear. Analysis based on low to high levels of fear indicated slightly increased moderate and high fear levels in female participants (47.5% and 52%, respectively) compared to male students (36.5% and 47%, respectively). Conclusion: The study suggests the need for significant attention to preventing dental fear. School-based health policies and parents should focus on psychosocial factors associated with the fear of dental treatment, as many of these factors are preventable. Dental anxiety poses challenges not only for patients but also for dentists, occasionally complicating the successful execution of treatments.

The Role of Family Factors in the Development of Dental Anxiety in Children.

Background and Objectives: In the literature, the influence of parents who suffer from dental anxiety and a previous unpleasant experience at the dentist are cited as the two most common causes of dental anxiety in children. The aim of this study is to investigate the relationship between socioeconomic factors and the development of dental anxiety in children aged 9 to 12 years. Materials and Methods: A total of 131 children and their accompanying parents/guardians participated in the cross-sectional study. The children were divided into an experimental group, which visited a specialised office for paediatric and preventive dentistry for the examination, and a control group, which visited a primary care dental office. During the visit, the children completed questionnaires on dental anxiety (CFSS-DS). Parents completed a socioeconomic questionnaire and a dental anxiety questionnaire for adults (CDAS). Results: The results showed a statistically significant positive predictor: parental dental anxiety as measured by the CDAS. In addition, the t-test showed that children who visited a specialised dental office did not show a statistically significant increase in dental anxiety compared to children who visited a primary care dental office. Conclusions: With this study, we confirm the influence of parental dental anxiety on the development of dental anxiety in children. The socioeconomic status of the family and the type of dental office do not play a statistically significant role in the development of dental anxiety in children.

Development and validation of the Iranian version of the Children's Experiences of Dental Anxiety Measure (CEDAM).

The aim of this study was to develop the Iranian version of the Children's Experiences of Dental Anxiety Measure (CEDAM) and evaluate its validity and reliability in assessing dental anxiety in children aged 9-16. The CEDAM was translated into Persian following the guidelines of the IQOLA project. A ‎sample of children completed the measure in a clinical setting, with a subgroup completing it ‎again to assess test-retest reliability. Concurrent criterion validity was evaluated by having all ‎participants complete the Modified Child Dental Anxiety Scale (MCDAS) alongside the ‎CEDAM. Construct validity was examined using exploratory and confirmatory factor ‎analyses.‎ RESULTS: The study included 275 children between the ages of 9 and 16. The Iranian version of CEDAM ‎exhibited excellent internal consistency with a Cronbach's ⍺ coefficient of 0.83. Test-retest‎reliability was also high, with an intraclass correlation coefficient value of 0.96. Furthermore, there was a significant and ‎positive correlation between CEDAM and MCDAS scores (ρ = 0.72, p < .01). Exploratory ‎factor analysis identified two factors, and confirmatory factor analysis confirmed that the ‎instrument aligned well with the factor structure obtained from the exploratory analysis.‎ CONCLUSION: This study provides evidence supporting the validity and reliability of the Iranian version of ‎CEDAM as a valuable tool for evaluating dental anxiety in Persian-speaking children between ‎the ages of 9 and 16.‎.

Efficacy of Virtual Reality Distraction in Reduction of Pain and Anxiety of Pediatric Dental Patients in an Iranian Population: A Split-Mouth Randomized Crossover Clinical Trial.

This crossover clinical trial was conducted with eligible 6-8-year-old children requiring bilateral mandibular molar pulpotomy. At the first treatment visit, pulpotomy was performed for 15 children using VR glasses distraction while the other 15 children received a pulpotomy without any VR glasses; this trend was reversed at the second session and pulpotomy was performed for the contralateral tooth. Pulse rate (PR) and Modified Child Dental Anxiety Scale (MCDAS) measured the anxiety levels. Wong-Baker Faces Pain Scale (WBFP) assessed the pain perception before and after the intervention. Data were analyzed by Statistical Package for the Social Sciences version 25 using the Mann-Whitney and χ2 tests. The mean PR was not significantly different between the two groups. However, the test group showed significantly lower scores of MCDAS (P value = 0.02) and WBFP (P value = 0.001) compared with the control group. The present results suggest that VR headsets can decrease the level of pain and anxiety of patients during primary mandibular pulpotomy. This trial is registered with IRCT20200315046782N1.

Evaluation of Child Preference for Dentist Attire and Usage of a Camouflage Syringe in Reduction of Anxiety.

This study aimed to evaluate the effect of child-friendly dentist attire and camouflage syringes on reducing dental anxiety in children. A cross-sectional study was conducted with 120 pediatric patients aged 6 to 12 years. Participants were assigned to one of three groups: group A (child-friendly dentist attire), group B (camouflage syringe), or group C (control group). Child preference for dentist attire was assessed using a visual analog scale, while dental anxiety was measured using the Modified Child Dental Anxiety Scale and the Facial Image Scale. The results showed a significant decrease in dental anxiety scores in both group 2 and group 3 compared to group 1 (P < 0.001). Children in group A exhibited a higher preference for child-friendly dentist attire [mean score: 8.7, standard deviation (SD): 1.2] compared to group 1 (mean score: 3.2, SD: 1.5) (P < 0.001). Similarly, children in group 2 showed a higher preference for a camouflage syringe (mean score: 8.5, SD: 1.3) compared to group 1 (mean score: 3.4, SD: 1.6) (P < 0.001). Child-friendly dentist attire and camouflage syringes were found to be effective in reducing dental anxiety among pediatric patients. These interventions were well received by children and their parents, highlighting the importance of considering child preferences in dental settings.

Evaluation of the effectiveness of tell-show-do and ask-tell-ask in the management of dental fear and anxiety: a double-blinded randomized control trial.

The objective of behavioral guidance is to establish effective communication that aligns with a child's requirements to manage disruptive behavior. This study aimed to evaluate the effectiveness of the Tell-Show-Do and Ask-Tell-Ask techniques in managing dental anxiety in children during their initial appointment. The study included 50 children (28 boys and 22 girls) without any prior experience between the ages of 7 and 11 at their first dental visit. The children were randomly categorized into two groups: Group 1, Tell Shows Do, and Group 2, Ask-Tell-Ask. Subsequently, all children underwent noninvasive treatment procedures such as restorations, sealants, and oral prophylaxis. Furthermore, behavioral management techniques were employed based on the allocated group. Finally, anxiety levels for all children were assessed using the Raghavendra, Madhuri, and Sujata Pictorial Scale (RMS-PS) and heart rate at three different intervals (before, during, and after). The obtained data were entered into Microsoft Excel, and statistical analysis was performed using SPSS software. A paired t-test and Mann-Whitney U-test were used to compare the mean and median values of the two groups and determine their effectiveness. Children in the TSD group exhibited statistically significant heart rates and RMS-PS scores in intra-group comparisons. However, children in the ask-tell-ask group showed a significant reduction only in the RMS-PS scores (P < 0.001) but not in the measures used to assess heart rate (P < 0.001). Tell-Show-Do was more effective than ask-tell-ask in alleviating dental anxiety in children. The simultaneous application of these two strategies can synergistically alleviate dental anxiety during a child's initial dentist appointment.

Reliability and validity of artificial intelligence-based innovative digital scale for the assessment of anxiety in children.

To assess the reliability and validity of an AI-based, innovative digital scale for the assessment of dental anxiety in children. Dental anxiety still persists as a potential problem in managing the child in the dental office. There is a need to develop a gold standard scale to measure anxiety in children incorporating newer technology. An innovative self-reported scale known as RMSDigital Anxiety Scale (RMS-DAS) incorporating artificial intelligence (AI) was developed. Seventy-six children (aged 4-12 years) were included in the reliability group. The RMS-DAS test score was recorded on Day 1 where the child was asked to click on the expression produced by AI that matches his/her anxiety level the most at that moment. RMS-DAS retest score was recorded after 7 days. The validity group included 140 children. The anxiety scores were recorded using three scales; RMS-DAS, RMS-Pictorial Scale (RMS-PS) and Facial Image Scale (FIS) during the same visit where the child was asked to click on the expression that matches his/her anxiety level the most at that moment. Reliability was assessed by the internal consistency using Cronbach's alpha and the test-retest was assessed using paired t-test, scatterplot, and coefficient correlation. The validity of RMS-DAS was assessed by correlating it with RMS-PS and FIS using Spearman's correlation coefficient. RMS-DAS is a reliable and valid scale that can be used as a new digital tool to assess children's dental anxiety.

Update on the effect of dental general anaesthesia on neurocognition in children.

Dental general anaesthesia provides a comfortable treatment modality for children with early childhood caries and children's dental anxiety, but US Food and Drug Administration safety warnings have raised concerns about the neurotoxicity of general anaesthetic drugs. Currently, anaesthetic drugs have been found to impair neurocognitive function in animals, with possible mechanisms including cell damage, cell loss and impaired neuronal network function. The outcomes of clinical studies on the neurocognitive effects of surgical general anaesthesia in children have been inconsistent. However, studies focusing on dental general anaesthesia in children suggest that it does not affect neurocognitive function. In general, a growing number of studies suggest that dental general anaesthesia does not affect neurocognitive development in children. Moreover, dental general anesthesia should be used as normal when other behavioural management is unavailable.