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Influence of Adapted Environment on the Anxiety of Medically Treated Children, with Developmental Disability as Compared to Typical Children

Dr. Michele Shapiro - Former head of the Snoezelen Field, Beit Issie Shapiro
Prof. Harold D. Sgan-Cohen - DMD MPH - The Hebrew University - Hadassah Faculty of Dental Medicine, Jerusalem
Prof. Shula Parush - School of Occupational Therapy, The Hebrew University of Jerusalem
Prof. Raphael N. Melmed - Israel S. Wechsler Professor Emeritus of Medical Education


Shapiro, M., Sgan-Cohen, H. D., Parush, S., & Melmed, R. N. (2009). Influence of adapted environment on the anxiety of medically treated children with developmental disability. The Journal of pediatrics154(4), 546-550


To examine the influence of a sensory adapted dental environment on the behavior and arousal levels of typical children in comparison to children with developmental disability during dental hygiene care.


Study Design
Sixteen children between the ages off 6-11 years old with developmental disability and 19 age-matched typical children participated in a trial measuring behavioral as analyzed by video and psychophysiological variables as analyzed by the amount of sweat on the skin (an indicator of stress, the more sweat, the higher the anxiety and the lower the Kohm measure), performed during a dental intervention.


Both groups performed better in the sensory adapted dental environment compared to the regular environment. The duration in minutes of anxious behaviors in the sensory adapted environment was 5.26minutes as opposed to 13.56 minutes in the regular dental environment. The amount of sweat levels during the treatment showed that in the sensory adapted dental environment there were 830 Kohms as opposed to 588 Kohms in the regular dental environment.


Findings indicate the importance of environment in determining the comfort level of all children. The greater difference between the two environments observed in children with DD suggests that this group benefits more from sensory adapted environments.




Many children, healthy, physically and developmentally disabled, are subjected to unnecessary pain and suffering and often fail to cooperate and overcome fear, during health care and treatment. Determining an optimal intervention that helps children to manage anxiety, distress, and pain is clearly desirable. Modes of potential treatments, which have been described, include: conscious sedation, stress-reducing medical devices, behavioral relaxation, pharmacologic analgesic and sedative interventions, hypnosis and many others. The present article addresses the option that modes of treatment in these situations could also include the sensory adaptation of clinical environments.

This study examines the influence of a sensory adapted dental environment, on developmentally disabled children and compares their responses to those of typical children. Dental clinics are usually characterized by noises, odors, bright lights, intrusive contact and anticipation of pain. This setting served therefore as a suitable model in that the essential elements listed above may be easily controlled. We hypothesized that children with developmental delay would find dental treatment a more stressful situation than typical children and that the children with developmental delay would be more positively influenced by a Sensory Adapted Dental Environment (SADE). This would be observed by duration of negative behaviors, and electro dermal activity prior to and during professional dental treatment.


Sensory Adapted Environment included:

Visual sensation: (a) No overhead fluorescent lighting (50 Hz) or dental overhead lamp. (b) Adapted lighting consisted of dimmed upward fluorescent lighting (30-40,000 Hz), slow moving, repetitive visual color effects ("Solar Projector", Rompa Co., Chesterfield, UK). (c) The dental hygienist wore a head mounted LED lamp (Black Diamond Zenix IQ, USA) directed into the patient's mouth.

Auditory and somato-sensory stimuli: Rhythmic music via loudspeakers (Dan Gibson's Solitudes: Exploring Nature with Music) at 75 db level with bass vibrator for soma-sensory stimulation (Aura, Bass Shaker, model AST-1B, 4 OHMS; Unical Enterprises, USA), connected to the dental chair producing soma-sensory stimulation.

Tactile stimulus: For children with DD, a "friendly butterfly" papoose "hugged" the child tightly.   For typical children a dental X-ray vest was placed on the child (deep "hugging" effect).  The Helsinki permission was granted for use of the butterfly for children with special needs as this has a restrictive function. This was supported by parent approval. The rationale for use of the physical restraint on DD patients is to preemptively reduce possible disruptive movements rather than rely on deeper sedation or general anesthetic (GA) to contain the problem. 1

Regular Environment (RE): Fluorescent lighting (50 Hz) and overhead dental lamp. The papoose "hugged" the DD child less tightly, only to ensure safety. The X-ray vest was not supplied for typical children.




This study confirms that the sensory adapted dental environment creates a significant calming effect for both developmentally delayed and typical children undergoing dental care. While both groups of children were significantly more relaxed during dental care in the sensory adapted dental environment, the results of this research indicate that children with developmental delay relaxed to a greater extent than did the typically developing children.

The study is consistent with previous observations. According to Grandin2, people with developmental delay, similarly to people with autism, are strongly influenced by the physical environment. This is because sensory processing disorders are persistent in this group, expressing itself as an inability to filter out distracting stimuli in the environment, leading to high anxiety levels.3 For this reason, when offering these children an environment in which aversive stimuli were substituted by gentler stimuli, like soft moving light effects, calming music and deep pressure, the children became more focused on the pleasant stimuli and their anxiety was reduced. The modified sensory environment results in the participants' attention being intently focused on the moving visual and auditory stimuli or the deep pressure, bringing about an "altered state" with the inevitable reduced awareness of discomforting or noxious stimuli, much as an altered state may reduce the intensity of pain in chronic pain sufferers.4

This phenomenon, as measured according to the amount of sweat on the skin (measured in Kohms) characteristically occurred rapidly on entering the sensory adapted dental environment rendering the DD children more relaxed.  The typical children, by contrast, are buffered from the sensory stimuli in some way and accordingly more independent of environmental factors.5

The findings of the present research should encourage the adaptation of the physical environment in order to minimize negative experiences of children with and without developmental disabilities as well as enhancing their positive participation.  The present study demonstrates that in the context of delivering medical and dental care to both typical and the very challenging group of developmentally delayed children, a sensory controlled environment may represent an important substitute for the commonly utilized alternatives of pharmacological sedation or even general anesthesia.





  1.  Kupiezkty A. Strap him down or knock him out: Is conscious sedation with restraint an alternative to general anesthesia? Br Dent J 2004; 196(3):  133‑140.

      2. Grandin T. Scariano MM. Emergence: labeled autistic. Novato C.A: Arena Press; 1986.

  1. Grandin T, Johnson C. Animals in translation. New York: Scribner; 2005: 1-27.

      4. Melmed RN. Mind, body and medicine: an integrative text. USA: Oxfor University Press; 2001 : 362-384.
      5. Miller LJ. Sensational kids. G.P. New York: Putman's Sons; 2006.


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  • Disabilities:

    Developmental Disability

  • Topics:

    Multi-Sensory Environments
    Therapeutic Methods

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