Psychosocial treatment of needle phobia in children

Psychosocial treatment of needle phobia in children
Specialty	psychology
	[ edit on Wikidata]

Last updated June 01, 2020

While needle phobia is not age-specific, it is more common in children than in adults. The latest research from all fields indicates that needle-fear is predominant among children fears with some research claiming that up to 93% of children experience [needle-related] stress."^[1] Many studies have been performed investigating psychosocial methods of helping children cope with their fear. Current research in this area has investigated several types of non-invasive treatments to aid children in their needle phobia. These can be categorized into distraction techniques and other methods. These techniques offer safer, cheaper alternatives to drug or anesthetic treatments (see Treatment).

Distraction treatments

Distraction treatments take advantage of the brain's inability to pay full attention to two things at once. Distraction works by passively or actively redirecting the child's attention away from the needle in the medical procedure at hand, leaving "less attention available to perceive pain."^[2] Taking the child's attention from the needle also lessens his or her ability to feel anxiety; this is important because a large part of needle phobia is the anticipatory stress caused by the needle. This phenomenon is referred to as an "analgesic effect," meaning "pain-relieving effect." Distraction treatments can be divided into passive and active distraction.^[3]

Passive distraction

Passive distraction is defined for the following studies as a form of distraction that commands the child's attention but does not require any participation on the child's part. The following studies used television to display movies or cartoons as a form of passive distraction. Several studies have investigated the analgesic effect that these can provide during venipuncture.^[2]

Active distraction

Active distraction is defined as a form of distraction that requires the patient's participation. Most of the studies investigating active distraction and its effect on children's fear of needles had the children play with a toy. Several also used nurses and the child's caregiver(s) to actively distract the child.^[2]

Studies investigating distraction treatments

Paediatric Nursing Magazine reviewed several studies that investigated distraction techniques for children during venipuncture.^[2] In one of the covered studies, Cohen concluded in a study that watching a children's movie decreased the child's stress, more so than having the child play with an "interactive toy.^[4]" Bellieni et al performed a comprehensive study on active and passive distraction at the University of Siena, Italy. They studied 69 children aged 7–12 that were scheduled to undergo venipuncture. To be included in the study, children had to fit all of the following criteria: ^{[ citation needed ]}

be between 7 and 12 years old
have eaten their last meal three hours or more prior to venipuncture
have no neurodevelopmental delay, including verbal difficulty
have had venipuncture less than once per year

Children were randomly assigned to one of three experimental groups: the control group, where venipuncture was performed without distraction (Group C); the active distraction experimental group, where venipuncture was performed while the mother distracted the child (Group M); and the passive distraction experimental group, where venipuncture was performed while the child watched a TV cartoon (Group TV). There were 23 children in each group; the average age and gender ratios of each group are shown in Table 1. The mothers in Group M were instructed to "actively distract their children during the venipuncture by speaking, caressing, and soothing them." The children in Group TV were placed in a room in front of a television; the cartoon started at least two minutes before the venipuncture took place, and the only distraction offered was an invitation for the child to watch the cartoon when it started playing.^[5]

**Mean age and gender ratio in treatment groups**
	Group C	Group M	Group TV
Number of Children	23	23	23
Median age (range)	8 (7-12)	9 (7-12)	9 (7-12)
Male/Female ratio	10/13	12/11	11/12

This study used the Oucher scale to assess pain in the children. The Oucher scale, a "validated visual pain scale scoring from 0 (no pain) to 100 (maximum pain)," has two separate scales to help children identify their pain level. The scale from 0 to 100 is placed alongside six photographs of children in various levels of discomfort; children in the report were asked to use the pictures as an aid for choosing a numerical value to represent their pain level. Parents of the children were also asked to assess their child's pain levels on the same scale, basing their assessment on the child's external indication of pain and not the child's reported score.^[5]

**Average Oucher Scale Ratings by Group**
	Mean	Standard Deviation
Group C	23.04	24.57
Group M	17.39	21.36
Group TV	8.91	8.65

The results of Bellieni's study suggest that passive distraction is more effective than active distraction in lessening perceived pain from venipuncture, although active distraction does have some effect in lessening perceived pain. The average scores on the Oucher scale for Group C, Group M, and Group TV were 23.04, 17.39, and 8.91, respectively; with standard deviation 24.57, 21.36, and 8.65, also respectively. Even taking these fluctuations in data into account, it is apparent that the passive distraction technique significantly lowered the perceived pain when compared to the control group and the active distraction group, according to both parents and children.^{[ citation needed ]}

These results show that distraction by television had a greater analgesic effect than active distraction performed by the mothers. This is shown by both the children's self-reported scores and the mothers' scores. Mason et al, who published a study in The Journal of Clinical Psychology in Medical Settings, suggested that while both mothers and television are effective distraction techniques, the mothers may have been less effective because the children's fear and distress could have affected their ability to interact with their mothers.^[6]

Influence of caregivers

In the Journal of Holistic Nursing, Cavendar et al performed a study investigating the effect of parents as active distraction to the child. Children in the experimental group received standard care, but the parents were given instruction in how to distract the child. Also, they were given a choice between three distraction items. The control group received standard care, and mothers were present in the room but were not coached on distraction techniques nor given distraction items. The researchers concluded that "fear was rated as significantly lower" in the experimental group, though there was "no statistical difference between the two groups with regard to pain and distress.^[7]"

The way parents act and react in situations where their child is undergoing venipuncture can have an effect on children and their fear of needles. In The Journal of Family Practice, James G. Hamilton hypothesized that "needle phobia is learned as well as inherited." He observed that "negative experiences associated with immunization, laboratory work, dental visits, and other medical procedures can condition children … toward becoming fearful of needles." Other factors, such as physical and verbal restraint during children's medical procedures, can influence children to fear needles and associated medical situations.^[8]

An article published in Nursing Forum by Ives et al outlined several helpful and unhelpful caregiver behaviors during venipuncture. Unhelpful behaviors included overly reassuring children, overly empathizing with children, apologizing, and criticizing children. It was also noted that giving the child control of the procedure from the beginning or asking the child to "indicate readiness to receive the needle" increased distress in the children. Other unhelpful responses included "inadequate or overly forceful restraint by the parent; shaming, threatening, yelling, slapping, lying; or, alternately, pitying, placating, bribing, and helpless parent behaviors." The researchers identified a need to provide instruction to parents on what not to say to their child.^[1]

Nurses identified lack of explanation to the child as a major problem in many immunization procedures. One nurse reported "getting kicked and hit by a struggling child" whose parents had not explained the purpose of the visit to the child. Despite the fear that the prospect of venipuncture may invoke, nurses agree that it is better to tell the child exactly what is going to happen beforehand.^[1] Nurses also reported that children's fear seemed to correlate with parents' anxiety, and cited parental anxiety as an obstacle in performing venipuncture.^[9]

Klieber found several helpful parent behaviors as a part of active distraction in his study published in the Journal of Pain and Symptom Management. These included using a calm voice, giving children permission to cry, remaining firm but not threatening, and using stickers to celebrate effort.^[10] The Nursing Forum article also found active and passive distraction by way of toys and television cartoons to be helpful. The researchers agreed that effective coaching and successful clinical visits involving venipuncture could provide children with an opportunity to practice and master "adaptive coping skills.^[1]"

Other techniques

Kettwich et al of the Department of International Medicine of the University of New Mexico conducted an experiment published in the Journal of Family Practice comparing decorated and plain syringes (see picture). The research hypothesis was that "adding decorative designs or stickers to medical devices before a procedure [would] significantly reduce aversion, fear, and anxiety…[in] needle-phobic patients." The experimental syringes were made with conventional 10-milliliter syringes, decorated so that the "markings of the barrel could still be seen".^[11]

In the experiment, "the presentation of individual devices to each subject was randomized to eliminate the possibility of a consistent bias." To determine emotional responses to the medical devices, the researchers used the validated Visual analogue scale where 0 denotes lowest response and 10 shows the strongest response. The Visual Analogue Scale for Aversion, Fear, and Anxiety were used. The study defined "significant needle phobia" as an "aversion, fear, or anxiety score of greater than or equal to 5." The results of this study showed that the stress-reducing medical devices are effective in reducing aversion, fear, and anxiety towards the medical needles. The results are shown in the table, in the form (Visual Analogue Score) ± (standard deviation).^[11]

**Reductions in aversion, fear, and anxiety with stress-reducing syringes**
	Conventional Syringes	Stress-reducing Syringes	P Value	% Decrease in Score
Aversion	5.88 ± (3.61)	1.21 ± (1.64)	P<.001	79%
Fear	4.68 ± (2.8)	2.19 ± (2.8)	P<.001	53%
Anxiety	4.54 ± (3.68)	2.21 ± (2.84)	P<.001	51%

For all three Visual Analogue tests, the mean score was much lower for the stress-reducing syringes; on average, the scores for the aversion, fear, and anxiety tests were 79%, 53%, and 51% lower, respectively.

Future research

Gemma Murphy, a staff nurse at the neonatal unit of University College London Hospital, suggested that future research should investigate types of passive distraction other than cartoons and movies. Murphy suggested studies comparing the effect of books, guided imagery, music, and virtual reality video glasses as other forms of passive distraction.^[2]

Related Research Articles

A phobia is a type of anxiety disorder defined by a persistent and excessive fear of an object or situation. The phobia typically results in a rapid onset of fear and is present for more than six months. The affected person goes to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the feared object or situation cannot be avoided, the affected person experiences significant distress. With blood or injury phobia, fainting may occur. Agoraphobia is often associated with panic attacks. Usually a person has phobias to a number of objects or situations.

Psychology is an academic and applied discipline involving the scientific study of human mental functions and behavior. Occasionally, in addition or opposition to employing the scientific method, it also relies on symbolic interpretation and critical analysis, although these traditions have tended to be less pronounced than in other social sciences, such as sociology. Psychologists study phenomena such as perception, cognition, emotion, personality, behavior, and interpersonal relationships. Some, especially depth psychologists, also study the unconscious mind.

In medicine, venipuncture or venepuncture is the process of obtaining intravenous access for the purpose of venous blood sampling or intravenous therapy. In healthcare, this procedure is performed by medical laboratory scientists, medical practitioners, some EMTs, paramedics, phlebotomists, dialysis technicians, and other nursing staff. In veterinary medicine, the procedure is performed by veterinarians and veterinary technicians.

Claustrophobia is the fear of confined spaces. It can be triggered by many situations or stimuli, including elevators crowded to capacity, windowless rooms, and hotel rooms with closed doors and sealed windows. Even bedrooms with a lock on the outside, small cars, and tight-necked clothing can induce a response in those with claustrophobia. It is typically classified as an anxiety disorder, which often results in panic attacks. The onset of claustrophobia has been attributed to many factors, including a reduction in the size of the amygdala, classical conditioning, or a genetic predisposition to fear small spaces.

Hypodermic needle Device to inject substances into the circulatory system

A hypodermic needle, one of a category of medical tools which enter the skin, called sharps, is a very thin, hollow tube with a sharp tip that contains a small opening at the pointed end. It is commonly used with a syringe, a hand-operated device with a plunger, to inject substances into the body or extract fluids from the body. They are used to take liquid samples from the body, for example taking blood from a vein in venipuncture. Large-bore hypodermic intervention is especially useful in catastrophic blood loss or treating shock.

Pediatric nursing is the medical care of neonates and children up to adolescence, usually in an in-patient hospital or day-clinic. Pediatrics comes from the Greek words 'paedia' which means child, 'iatrike' which means physician. 'Paediatrics' is the British/Australian spelling and 'pediatrics' is the United States spelling.

Fear of needles, known in medical literature as needle phobia, is the extreme fear of medical procedures involving injections or hypodermic needles.

Aichmophobia is a kind of specific phobia, the morbid fear of sharp things, such as pencils, needles, knives, a pointing finger, or even the sharp end of an umbrella and different sorts of protruding corners or sharp edges in furnitures and building constructions/materials. It is derived from the Greek aichmē (point) and phobos (fear). This fear may also be referred to as belonephobia or enetophobia.

Clown Care program in health care facilities involving visits from specially trained clowns

Clown Care, also known as hospital clowning, is a program in health care facilities involving visits from specially trained clowns. They are colloquially called "clown doctors" which is a trademarked name in several countries. These visits to hospitals have been shown to help in lifting patients' moods with the positive power of hope and humor. There is also an associated positive benefit to the staff and families of patients.

Social inhibition is a conscious or subconscious avoidance of a situation or social interaction. With a high level of social inhibition, situations are avoided because of the possibility of others disapproving of their feelings or expressions. Social inhibition is related to behavior, appearance, social interactions, or a subject matter for discussion. Related processes that deal with social inhibition are social evaluation concerns, anxiety in social interaction, social avoidance, and withdrawal. Also related are components such as cognitive brain patterns, anxious apprehension during social interactions, and internalizing problems. It also describes those who suppress anger, restrict social behavior, withdraw in the face of novelty, and have a long latency to interact with strangers. Individuals can also have a low level of social inhibition, but certain situations may generally cause people to be more or less inhibited. Social inhibition can sometimes be reduced by the short-term use of drugs including alcohol or benzodiazepines. Major signs of social inhibition in children are cessation of play, long latencies to approaching the unfamiliar person, signs of fear and negative affect, and security seeking. Also in high level cases of social inhibition, other social disorders can emerge through development, such as social anxiety disorder and social phobia.

Dental fear is a normal emotional reaction to one or more specific threatening stimuli in the dental situation. However, dental anxiety is indicative of a state of apprehension that something dreadful is going to happen in relation to dental treatment, and it is usually coupled with a sense of losing control. Similarly, dental phobia denotes a severe type of dental anxiety, and is characterised by marked and persistent anxiety in relation to either clearly discernible situations or objects or to the dental setting in general. The term ‘dental fear and anxiety’ (DFA) is often used to refer to strong negative feelings associated with dental treatment among children, adolescents and adults, whether or not the criteria for a diagnosis of dental phobia are met. Dental phobia can include fear of dental procedures, dental environment or setting, fear of dental instruments or fear of the dentist as a person. People with dental phobia often avoid the dentist and neglect oral health, which may lead to painful dental problems and ultimately force a visit to the dentist. The emergency nature of this appointment may serve to worsen the phobia. This phenomenon may also be called the cycle of dental fear. Dental anxiety typically starts in childhood. There is the potential for this to place strains on relationships and negatively impact on employment.

Blood-injection-injury (BII) type phobia is a type of specific phobia characterized by the display of excessive, irrational fear in response to the sight of blood, injury, or injection, or in anticipation of an injection, injury, or exposure to blood. Blood-like stimuli may also cause a reaction.This is a common phobia with an estimated 3-4% prevalence in the general population, though it has been found to occur more often in younger and less educated groups.

Most people suffer from a form of fear of medical procedures during their life. There are many different aspects of this fear and not everyone has every part. Some of these parts include fear of surgery, fear of dental work, and fear of doctors. These fears are often overlooked, but when a patient has one to the extreme it can be very damaging to their health.

Preoperational anxiety, or preoperative anxiety, is a common reaction experienced by patients who are admitted to a hospital for surgery. It can be described as an unpleasant state of tension or uneasiness that results from a patient's doubts or fears before an operation.

Pain in babies, and whether babies feel pain, has been a large subject of debate within the medical profession for centuries. Prior to the late nineteenth century it was generally considered that babies hurt more easily than adults. It was only in the last quarter of the 20th century that scientific techniques finally established babies definitely do experience pain – probably more than adults – and developed reliable means of assessing and of treating it. As recently as 1999, it was commonly stated that babies could not feel pain until they were a year old, but today it is believed newborns and likely even fetuses beyond a certain age can experience pain.

A childhood phobia is an exaggerated, intense fear “that is out of proportion to any real fear” found in children. It is often characterized by a preoccupation with a particular object, class of objects, or situation that one fears. A phobic reaction is twofold—the first part being the “intense irrational fear’ and the second part being “avoidance.”

Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment. It is most common in infants and small children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Separation anxiety is a natural part of the developmental process. Unlike SAD, normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem.

Eurotophobia is the aversion to or dislike of female genitalia.

Pain management in children is the assessment and treatment of pain in infants and children.

References

1 2 3 4 Ives, Mary and Sherri Melrose. "Immunizing Children Who Fear and Resist Needles: Is It a Problem for Nurses?" Nursing Forum (2010): 29-39.
1 2 3 4 5 Murphy, Gemma. "Distraction techniques for venepuncture: a review." Paediatric Nursing (2009): 18-20.
↑ Fung, Elizabeth. "Psychosocial management of fear of needles in children." Haemophilia (2009): 635-636.
↑ Cohen, L., R. Manimala and R. Blount. "Easier said than done: What parents say they do and what they do during children's immunizations." Children's Health Care (2000): 79-87.
1 2 Bellieni, C. V., et al. "Analgesic effect of watching TV during venipuncture." Archives of Diseased Children (2006): 1015-1017.
↑ Mason, S., M. H. Johnson and C. Wooley. "A comparison of distractors for controlling distress in young children during medical procedures." Journal of Clinical Psychology in Medical Settings (1996): 239-248.
↑ Cavendar, K et al. "Parents' positioning and distracting children during venipuncture effects on children's pain, fear and distress." Journal of Holistic Nursing (2004): 32-56.
↑ Hamilton, James G. "Needle phobia: A neglected diagnosis." Journal of Family Practice (1995): 169-175.
↑ Duff, A. "Incorporating psychological approaches into routine paediatric venipuncture." Archives of Disease in Childhood (2003): 931-937
↑ Kleiber, C. et al. "Parents as distraction coaches during IV insertion: a randomized study." Journal of Pain and Symptom Management (2001): 851-861.
1 2 Kettwich, Sharon C., et al. "Patients with needle phobia? Try stress-reducing medical devices." The Journal of Family Practice (2006): 697-700.

External links

, Information about the Oucher Scale

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.

[Ives-1] 1 2 3 4 Ives, Mary and Sherri Melrose. "Immunizing Children Who Fear and Resist Needles: Is It a Problem for Nurses?" Nursing Forum (2010): 29-39.

[Murphy-2] 1 2 3 4 5 Murphy, Gemma. "Distraction techniques for venepuncture: a review." Paediatric Nursing (2009): 18-20.

[3] Fung, Elizabeth. "Psychosocial management of fear of needles in children." Haemophilia (2009): 635-636.

[4] Cohen, L., R. Manimala and R. Blount. "Easier said than done: What parents say they do and what they do during children's immunizations." Children's Health Care (2000): 79-87.

[Bellieni-5] 1 2 Bellieni, C. V., et al. "Analgesic effect of watching TV during venipuncture." Archives of Diseased Children (2006): 1015-1017.

[6] Mason, S., M. H. Johnson and C. Wooley. "A comparison of distractors for controlling distress in young children during medical procedures." Journal of Clinical Psychology in Medical Settings (1996): 239-248.

[Cavendar-7] Cavendar, K et al. "Parents' positioning and distracting children during venipuncture effects on children's pain, fear and distress." Journal of Holistic Nursing (2004): 32-56.

[Hamilton-8] Hamilton, James G. "Needle phobia: A neglected diagnosis." Journal of Family Practice (1995): 169-175.

[9] Duff, A. "Incorporating psychological approaches into routine paediatric venipuncture." Archives of Disease in Childhood (2003): 931-937

[10] Kleiber, C. et al. "Parents as distraction coaches during IV insertion: a randomized study." Journal of Pain and Symptom Management (2001): 851-861.

[Kettwich-11] 1 2 Kettwich, Sharon C., et al. "Patients with needle phobia? Try stress-reducing medical devices." The Journal of Family Practice (2006): 697-700.