Abstract
Background: Stress is a natural automatic reaction of organisms to challenging or threatening stimuli. Prevalence rates reveal an increasing number of students both in elementary and secondary education suffering from anxiety and other stress-related disorders and illnesses [The Journal of Pediatrics. 2009 Mar;154(3):322–6]. Literature shows a plethora of stress management techniques being used with children and adults to achieve stress reduction and inner peace. This narrative review primarily aimed at summarizing evidence-based relaxation techniques currently used by minors, contrasting them with data from the past and directions for the future. *(Additional content can be found at the bottom page of this review). Summary: Literature research revealed a plethora of stress management techniques, including breathing practices or exercises, meditation, guided imagery, clinical hypnosis, cognitive behavioral therapy, behavioral therapy, third wave therapies, interpersonal therapies, progressive muscle relaxation, autogenic training, biofeedback training, and mindfulness, that are deemed to be effective to treat stress and a variety of stress-related disorders such as anxiety disorders, depression, post-traumatic stress disorder, obsessive-compulsive disorder (OCD), headaches, abdominal pain, perioperative anxiety and postoperative pain, cancer, and attention-deficit hyperactivity disorder. These evidence-based stress management techniques have been successfully employed in various settings such as schools, waiting rooms, dental offices, or inpatient settings. Key Messages: Stress management techniques used by children and adolescents are important to reduce anxiety, stress, and depressive symptoms, improve social skills, reduce stress-related physical pain, and achieve academic improvement across settings and diagnoses.
Introduction
Stress is defined as “a state of threatened or perceived as threatened homeostasis.” [1] A range of external, true, or perceived stressful events (stressors) mobilizes the “stress system” of the organism to re-establish body homeostasis by a series of behavioral and physiological adaptive responses [1]. Children and adolescents are exposed to a variety of stressors in daily life, including the absence of a supportive caregiver [2], poverty [3], friendship and interpersonal difficulties, heavy academic workload [4, 5], or bullying [6], to name a few [7]. It is becoming clear that the ability of children and adolescents to cope with stress is recognized as of major importance.
About 35% of children in America experience stress-related health problems [8], while one of the most common stress-related symptoms is recurrent abdominal pain (RAP), affecting 10–30% of all school-aged children [9]. Other somatic symptoms, according to literature, include headaches [10, 11], heart/chest pain, nausea, constipation, arm/leg pain, diarrhea, and vomiting [11], with headaches being the most prevalent somatic complaint and abdominal pain (AP) the most prevalent gastro-intestinal symptom [11]. The same stress-related symptoms are shared with anxiety disorders, which are considered the most common mental health problem during childhood and adolescence, with lifetime prevalence rates ranging from 9% to 30% [12].
Past
Sigmund Freud, “the father of modern psychology,” was the very first to introduce children to psychodynamic psychotherapy back in 1909. He introduced play therapy by supervising the treatment of a five-year-old boy, who is known in the history of psychoanalytic psychotherapy as the case of “little Hans” [15]. Almost a decade later, in 1921, play therapy was formally introduced by Hug-Hellmuth, but it was not until the 1960s that Anna Freud (1965) published her study on the biopsychosocial developmental stages of the child, underlying the belief that a child’s play may keep a symbolic unconscious meaning [16]. Literature revealed that in the middle of the 20th century, psychiatric training programs in the USA were training residents in psychodynamic psychotherapy [15].
During the 1970s, a number of scientific articles investigating the effectiveness of relaxation training with children appeared in the literature. Despite methodological issues, such as imprecise definition of populations and irregularity of dependent variables in different studies, findings suggested that relaxation training techniques were effective for various learning, behavioral, even physiological disorders of childhood [15]. It is also important to mention that the 1980s played a critical role in identifying stress management techniques in a more similar form to what is used nowadays. In 1988, 10–20% of American children were considered to be suffering from some form of psychological or physical illness, probably connected to stress [16]. Significantly, teaching relaxation techniques to children themselves, along with education on illness in and out of the school environment, was considered the primary shield against stress [16]. Similar results were identified in a study conducted in 1985 [17]. However, it is quite interesting that an earlier study from 1983 supported the idea of stress management techniques as well, even though it was conducted only by pediatricians strictly in cases of traumatic and stressful events. Stress and anxiety could be identified when children were encouraged to engage in creative play, which was seen as a therapeutic coping mechanism in itself. Therefore, not only encouraging the participation in play activities and at an older age (school age), but also developing skills in order to learn to deal with stressful situations, were considered pioneering scientific ideas of that time [18].
Present – Relaxation Techniques Used by Children and Adolescents
Current literature offers an abundance of evidence-based, non-pharmacologic stress management techniques for children and adolescents that can be practiced in a hospital, a school setting, or even in the privacy of one’s home, covering a variety of issues, ranging from stress-related pains and aches to serious illnesses, such as childhood cancer, asthma, or psychiatric disorders, including but not limited to attention-deficit hyperactivity disorder (ADHD) [12, 19‒22].
Breathing Practices (Breathing Exercises)
“Breathing practices entail voluntary changes in the rate, pattern, and quality of respiration,” while they are also considered to be fundamental to physical, emotional, and spiritual development that help release tension, reduce stress, anxiety, and depression [19, 23, 24]. Furthermore, deep slow breathing improves autonomic functioning by increasing parasympathetic activity and reducing sympathetic activity, in particular improving vagal tone, thus reducing heart rate and blood pressure [20].
Innumerable variations, producing different psychophysiological effects, have been identified through literature research [23].
Paced breathing: control of the respiratory rate and the relative length of four phases of the breathing cycle.
In coherent or resonance breathing: inhales and exhales are of equal length with only a slight pause in between. Other scheme uses 4 counts in, 4 counts breath hold, 6 counts out, and 2 counts breath hold.
Resistance breathing: partial obstruction of airflow using laryngeal contracture, vocal cords, and pursed lips, resulting in sounds and vibrations.
Unilateral or alternate nostril breathing: inhaling through one nostril while closing the other, so that all air flows through one nostril. Exhaling through the alternative nostril while closing the one that was originally used.
“Moving” the breath engages the imagination to move one’s breath through different parts of the body, sending it to parts that are aching or are tense, with or without verbal guidance.
Breathing with movement: paced breathing while performing physical movements [23].
Diaphragmatic breathing (abdominal/belly/deep breathing) is marked by expansion of the abdomen rather than the chest when breathing. It helps in decreasing oxygen consumption, decreasing heart rate and blood pressure, and increasing parasympathetic activity [7].
Mindful breathing is a basic guided breathing meditation practice that sustains attention and focuses on breathing (the natural rhythm of each inhale and exhale). These short breathing exercises foster the attention and emotion regulation, supporting body awareness while influencing the amygdala through complex neural pathways at the same time [4, 25].
Meditation Techniques
“A family of techniques which have in common a conscious attempt to focus attention in a nonanalytical way and attempt not to dwell on discursive, ruminating thought” [26] Four general features of meditation procedures are noted in these kinds of techniques: a quiet environment, an auditory stimulus to dwell upon (e.g., a “mantra”) or a visual stimulus, and also a passive attitude and a comfortable position are required. A plethora of specific meditation procedures are described thoroughly in the literature [27]. Mind-body interventions can have a preventative impact on the stress response system and stress-related deficits, while meditation has been shown to increase brain activation in the medial prefrontal cortex in adults, which suggests an improved ability for emotion [28].
Guided Imagery
“Guided imagery is the use of mental visualization (mental images) to improve mood and physical well-being.” [29] It consists of a combination of behavioral interventions (body relaxation) and cognitive interventions (guided imagery), which provide a noninvasive way to achieve self-regulation. Guided imagery is considered to be appropriate for children and adolescents. The process consists of three “active” phases that generate new internal experiences.
Body relaxation which helps the child to focus on the body. Specifically, it suggests the gradual release of muscle tension, starting from the bottom (feet), moving all the way up to the head while taking deep breaths.
Imagery is a spontaneous or deliberate mental reconstruction of sights, sounds, smells, tastes, and feelings, as if they are actually happening and being experienced during this process. At this phase, the child is asked to visualize a favorite place or favorite experience in a place, whether real or not, using the same words for each participant.
Return to reality: the child remains in the chosen place for a while, knowing that they could mentally return to this positive experience whenever they want. Subsequently, the contact with the surrounding environment is gradually resumed until the child opens their eyes [30].
Clinical Hypnosis
Clinical hypnosis consists of relaxation and mental imagery to learn to break away from the stressful environment [31]. Alternatively, it is an interaction in which the hypnotist uses suggested scenarios (“suggestions”) to encourage a person to focus on inner experiences. Hypnosis is used to influence perceptions, emotions, thoughts, and behavior of an individual and to replace dysfunctional ones with more effective ones [32].
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a highly structured psychological therapy [33]. It consists of a group of related techniques utilizing a set of overlapping cognitive and behavioral procedures [34]. CBT aims to change a wide range of internal processes – thoughts, beliefs, emotions, misconceptions, and reasoning prejudices biases – and obvious/apparent dysfunctional behaviors, replacing them with more practical and effective ones. Through collaboration and guidance, the individual learns to recognize, re-evaluate, and replace negative and undesirable thought patterns, thus changing their choices and behavior [33].
Behavioral Therapy
Behavioral therapy is a group of techniques derived from behavioral models of psychology that seek to modify maladaptive behaviors without attempting to change the thought patterns of the individual [34].
Third Wave Therapies
Third-wave therapies prioritize the holistic promotion of well-being over the reduction or elimination of the symptomatology. They combine psychological, cognitive, and behavioral principles related to CBT, mindfulness, acceptance, spirituality, and personal values. To be categorized as a third wave, intervention should focus on modifying the relationship of the individual to their thoughts and feelings rather than modifying the content of their thoughts or reducing/eliminating their emotions [34].
Interpersonal Therapies
Interpersonal therapy techniques primarily focus on the relationship between young people and significant adults (e.g., parents, teachers), and their main focus is on improving communication skills between them [34].
Progressive Muscle Relaxation
Progressive muscle relaxation (PMR) was first recognized by Jacobson in 1934 as a procedure that involved tensing and releasing the 16 muscle groups; it is probably one of the most widely used relaxation procedures. It consists of tensing and relaxing various muscle groups in a scripted sequence, as the patient turns their attention to the contrast between a tense and relaxed muscle. The person is instructed to tense a group of muscles during inhalation and release the tension on exhalation, working with each muscular group in turn. Paying attention to this contrast between tense and relaxed muscles assists the client to develop awareness of tense and relaxed psychological states. Gradually, the muscle groups are combined, and eventually, the ability to relax without tensing first is formed [35]. Later, Wolpe adapted the PMR techniques for use with systematic desensitization in 1948, and much later, Bernstein and Borkovec (1973) studied technique adaptations to suit cognitive behavioral stress management [36]. There is evidence that supports the use of PMR in high-intensity reactions, such as the tension reduction of headaches, insomnia, adjunctive cancer treatment, management of chronic inflammatory arthritis pain, and irritable bowel syndrome [36].
Autogenic Training
Autogenic training utilizes autosuggestion to bring about a relaxed state. The basic program is being formed by six standard exercises, which include suggestions of limb heaviness, limb warmth, reduced heart rate, reduced respiration rate, abdominal warmth, and forehead cooling. After obtaining a comfortable posture, the individual listens to recorded instructions and silently repeats the specific self-suggestion, e.g., “My arm is comfortably heavy.” As the individual maintains focused attention to the process described in the self-suggestion, the desired effect of deep physical relaxation usually occurs shortly after [37].
Biofeedback Training
“Biofeedback training provides an enhanced capacity for the individual to monitor physiological indices of bodily relaxation or arousal.” In biofeedback training, this ability is being monitored by instruments, usually electronic, which measure the physiological responses, over which the individual attempts to exercise voluntary control [38]. In other words, it can be defined as the use of electronic or electromechanical equipment to measure information about the normal processes of an individual who is then able to intervene and change their physiological response [39].
PRISM
PRISM is based on traditional CBT methods but deliberately deviates from those provided preventatively with short skill-based training. It was developed based on theories of resilience and stress reduction and consists of 4 individual sessions, lasting 30–50 min each. Its main components are “stress management,” “goal setting,” “cognitive restructuring,” and “benefit finding” [40].
Mindfulness
“Mindfulness is defined as the awareness that arises through intentionally attending to one’s moment-to-moment experience in a nonjudgmental and accepting way. Mindfulness seeks to bring into awareness, in a specific way, a person’s relationship to their experiences (thoughts, emotions, and behaviors).” [41] In other words, mindfulness is the cognitive tendency to be aware of what is happening at the present time, without judgment or attachment to any particular outcome [4]. The primary element of mindfulness practice is to focus on the breath. Other key elements are the ability to coordinate events that take place within the body and mind, and the act of witnessing one’s personal experience [4]. The 8-week mindfulness-based stress reduction program, developed by Jon Kabat-Zinn at the University of Massachusetts Medical School, is perhaps the most well-known and researched mindfulness intervention in the scientific literature. It consists of weekly group-based classes lasting 2–2.5 h with a trained teacher, daily audio-guided home practice, and a day-long mindfulness retreat [42]. Formal mindfulness training practices aim at educating individuals on multiple features of attention, such as noticing when the mind wanders, repeatedly reorienting attention back to a focus area, developing constant attention, and learning how to cultivate an open and accepting form of attention so as not to get carried away in thoughts, emotions, or body sensations [42]. Mindful breathing has been reported to regulate the autonomic nervous system, focus the mind, and increase self-awareness [4]. Mindfulness-based techniques combined with socio-affective and socio-cognitive practices have been found to decrease perceived stress in school-age children [43].
Selected Disorders and Use of Relaxation Techniques
Anxiety Disorders and Depression
Common mental disorders are a major cause of morbidity in children and young people under the age of 18 years. According to the World Health Organization, anxiety disorders are considered the 5th most frequent cause of disability-adjusted life-years lost for adolescent girls. At the same time, depressive disorders are ranked as the 3rd most common cause of adolescent disability-adjusted life-years lost for children and adolescents in general (<18 years old) [44]. To date, most controlled trials for anxious children and adolescents have evaluated the effectiveness of broad-based CBT protocols, designed to treat a range of diagnoses. A meta-analysis of 41 studies (1,806 participants) concluded that CBT was more effective than waiting list control conditions, with remission rates of 59% compared with 16% for waiting list control conditions [45]. A well-established state of the effectiveness of CBT use on children with anxiety disorders was revealed by a review of 111 studies, analyzing the six variants of CBT (CBT, exposure, modeling, CBT with parents, education, and CBT combined with medication) [12, 19]. Results from another systematic review showed that programs aimed at reducing depression and/or anxiety symptoms in adolescents are generally effective; however, stress reduction programs may not always be [46]. Furthermore, this study identified that dose and race of participants affected the effectiveness of depression programs. Knowing how gender, dose, and race can mitigate program effectiveness is important to increase the effectiveness of future programs [46].
Three psychological therapies have received empirical support for the treatment of childhood and adolescent depression: CBT, interpersonal psychotherapy, and family therapy with CBT being the most widely explored [12]. A recent review of psychosocial treatments for depression identified 42 published RCTs [47]. Within child samples (7 RCTs), CBT was found to be superior to waiting list control conditions but was not consistently found to be superior to other active controls or alternative evidence-based treatments, just to meet the potentially efficacious treatment status. In contradiction, 27 RCTs evaluated the effectiveness of CBT in adolescent samples with CBT found to be superior to waiting list control conditions, active controls, and alternative treatments. Thus, for adolescents, CBT is considered a well-established treatment. The same review identified interpersonal psychotherapy with enough evidence to be considered as a well-established treatment for depressed adolescents; however, only 6 RCTs were conducted [47].
To our knowledge, only one systematic review and meta-analysis was identified with conflicting result to research [34]. The techniques identified were the use of relaxation and mindfulness, biofeedback training, CBT or under certain circumstances only behavioral therapy, interpersonal therapies, and third wave therapies (combination of the basic principles of CBT – mindfulness – acceptance – flexibility) [34]. According to this particular research, there was a lack of evidence to support that each individual type of intervention in preventing depressive symptoms in general and anxiety symptoms. But the promising finding is that mindfulness and relaxation-based interventions showed a reduction in anxiety symptoms compared to the usual curriculum or no intervention [34].
Post-Traumatic Stress Disorder
Prolonged stress – due to abusive/maltreatment events (e.g., sexual abuse) – particularly at critical times of brain development (such as infancy and adolescence), can bring about changes in the brain and brain functioning later in life [48]. As a result, traumatized children may experience profound changes in the way they view themselves and others. Many of them may sustain psychobiological changes that contribute to the development of post-traumatic stress disorder (PTSD). CBT is designed to help alleviate these symptoms by using a range of techniques to detect and then replace maladaptive thoughts at the basis of PTSD. Literature review findings showed evidence that suggests the use of CBT may have positive effects in reducing the symptoms of depression, PTSD, and anxiety symptoms [45].
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is a psychiatric condition that affects up to 3% of the population and with typical onset in childhood [49]. The use of CBT to treat childhood anxiety has repeatedly been shown [50, 51] to be effective and superior to control conditions and is considered the gold standard for the treatment of anxiety disorders such as OCD in children [52]. Even though minor concerns have been raised concerning CBT not demonstrating as significant clinical benefits as other active treatment conditions [45], these concerns have not been supported in the empirical literature. CBT for OCD encompasses a range of techniques, including psychoeducation, exposure, and cognitive restructuring, designed to help youth face feared situations to develop coping skills [49]. A recent study found evidence that supports the hypothesis that both anxiety and depressive symptoms would improve over the course of OCD treatment with the use of CBT therapy [49]. Similarly, researchers also support the hypothesis that CBT treatment responders would demonstrate steeper slopes of improvement in anxiety and depression compared to their nonresponsive counterparts [49].
Headaches
Headache is the most frequent stress-related neurological symptom in childhood [10], while tension-type headaches and migraines are the most frequent types of primary headache in children and adolescents emerging to the emergency department [50]. A meta-analysis showed that biofeedback was effective as a prophylaxis for migraine in children [31]. Children and adolescents who learned self-hypnosis for recurrent headaches reported significant relief in frequency (from average 4.5 per week to 1.4 per week), intensity, and duration (median duration of 23.6 h–3.0 h duration) of headache episodes [47, 53].
Abdominal Pain
Chronic pain is considered a significant problem in the pediatric population along with stress-related pains and aches such as RAP or as it is otherwise referred to as chronic AP [9, 11]. RAP is characterized by the recurrence of at least three episodes of AP over a period of 3 months, severe enough to interfere with the child’s activities [54]. Earlier studies have demonstrated an association between childhood functional AP and short- and long-term comorbidity, including depression, anxiety, social phobia, and somatic complaints [11, 49], which decrease quality of life, increase school absenteeism, disrupt family activities, and increase the possibility of an economic impact upon the family [11]. According to literature, children refractory to conventional therapy for AP experienced a reduction in AP during and after relaxation and guided imagery training [49]. Along with the use of clinical hypnosis in a patient undergoing surgery for AP and Crohn’s disease, the findings showed a free of complications recovery, reduced AP, and overall, a successful surgery [53].
Cancer-Related Anxiety
Children with cancer often undergo many painful, traumatic, and anxiety-producing procedures [22]. Literature findings reveal that when children receive various combinations of distraction, relaxation, or imagery techniques (whether performed by a trained practitioner or a trained parent), this results in a reduction in children’s anxiety and perception of pain [22]. Similarly, the use of biofeedback-assisted relaxation training (belly breathing) in children undergoing chemotherapy has reduced anxiety and improved coherence scores on heart rate variability [55]. Improved sleep has been reported as a result of deep breathing and PMR techniques [56]. A meta-analysis of 11 psycho-oncological cancers (breast, prostate, hematological, gynecological, gastro-intestinal, neurological, etc.) summarizes, among others, that mindfulness-based relaxation techniques are quite effective in stress and anxiety relief, improving overall quality of life and depressive symptoms, helping patients feel more open to new and novel experiences, sleep disturbance, and fatigue [57]. Finally, a recent (2018) randomized controlled trial aimed at improving resilience in adolescents and young adults correlated the use of PRISM (mindfulness techniques, relaxation strategies, obtaining social support) with improved patient-reported resilience, cancer-related quality of life, and reduced psychological distress [40].
Perioperative Anxiety and Postoperative Pain
Surgery is a stressful event for children, regardless of the intervention. Side effects, such as nausea, insomnia, nightmares, and emotional and behavioral discomfort, are often experienced by children during the presurgical period [52] and often after being discharged from the hospital [51]. A study on preoperative anxiety and postoperative pain in 60 children (6–12 years old) [26] showed that the relaxation-guided imagery group had significantly reduced preoperative anxiety and postoperative pain. In particular, the level of preoperative anxiety, during the induction of anesthesia, was significantly lower for the children of the experimental group compared to those of the control group. Similarly, the level of postoperative pain was significantly lower in the experimental group than in the control group [30]. In addition, the effective use of clinical hypnosis to help adolescents cope with common medical conditions that require operative procedures was the main finding in another study in adolescents [53]. Using both relaxation/guided imagery and clinical hypnosis, patients recognized that the surgery was successful, dealt with recovery time without any complications, and AP was reduced in all patients [53]. These findings are consistent with other literature findings that insist on the positive effects of relaxation techniques in children undergoing surgeries [58].
Attention-Deficit Hyperactivity Disorder
A child with ADHD demonstrates an inability to sit still, concentrate, self-regulate, apply self-control, and maintain a consistent schoolwork performance [59]. As evidenced by numerous studies, the positive effects of relaxation training in children include decreased dysfunctional behavior, reduced stress and anxiety levels, alleviated headaches, encouraged reading achievement, improved self-awareness, and enhanced self-esteem [60]. Findings from previous research studies have shown that the use of yoga and meditation has positive benefits for children with ADHD in improving concentration, classroom behavior, and emotional development [61]. Similar effects on their attention span, which could lead to improved learning, have been identified when they bring mindfulness and mindful breathing into the classroom [4, 25]. Similarly, the use of biofeedback has shown improvements in ADHD symptoms and related behaviors [62‒64].
Relaxation Techniques in Different Settings
Mindfulness at School
Public interest and the implementation of mindfulness-based interventions (MBIs) in schools have seen an explosive growth in recent years [64]. Mindfulness-based curricula have been introduced in K-12 schools across the USA, as a way to reduce stress, increase attention, enhance positive perspective and effective emotional regulation [65]. MBIs in the school environment have become increasingly popular in recent years, in an effort to relieve children of stress and encourage learning and creativity [66]. Schools are ideal settings for providing such services to young people, and raising awareness offers much potential as a means of improving the youth’s well-being and mental health [64]. The main concept is that if students can learn to be “fully present,” they can increase the quality of their learning performance by being more focused and able to deal with stressful situations [26]. An extensive systematic review and meta-analysis of school mindfulness, which examined 24 studies, including children aged 6–19 years old, showed that MBIs in school settings are promising, particularly in terms of improving cognitive performance and stress resilience [66].
It is generally accepted that students with learning disabilities often have higher levels of anxiety and school-related stress compared to their typically developing peers [20]. A pilot study of 34 adolescents diagnosed with learning disabilities examined the effects of mindfulness mediation treatment on student stress and anxiety. Outcome measures showed significant improvement, with participants who completed the program experiencing decreased state and trait anxiety, enhanced social skills, and improved academic performance [20].
Relaxation Techniques in the Waiting Room and in Inpatient Settings
In recent years, patients and families have increasingly used mobile applications as a relaxation and distraction intervention for children with complex chronic medical conditions in the waiting room setting or during hospitalization [67]. In 2017, surveys were conducted in three major smartphone application platform stores (Blackberry World App, App Store iOS, and Google Play), and 22 applications with relaxation techniques were identified. Sixteen of them were included in a study for further investigation. In more detail, an application is identified as ideal for infants and preschoolers and aims to use the game simulation for introduction to breathing exercises. For six of the applications, the suggested age of use is elementary school and above. These applications include breathing exercises, meditation techniques, and relaxing audio sounds. Only one application that includes meditation, yoga, and cognitive therapy techniques has been identified for use by adolescents and older ones. The remaining apps do not have any age limitation and can be used by all age groups. Applications include real-time video chat (relational and creative), soothing audio sounds, and relaxing visual images. Further research should be conducted to investigate the effectiveness of these applications in clinical practice [67].
Relaxation Techniques in Dental Offices
Dental anxiety, or anxiety associated with the thought of visiting the dentist, is commonly seen in childhood and adolescence [67], while anxiety can be a prognostic factor for increased pain perception [68]. According to McCaul and Mallot [69], distracting a child from an unpleasant stimulus can result in reduced perception of pain. Relaxation exercises are known to boost vagal activity, increase the production of neurotransmitters against pain such as serotonin, and decrease the stress hormone levels [67]. Counter stimulation and virtual reality methods could be used to reduce pain and anxiety in the local anesthesia (LA) injection during extraction and pulp treatments [70]. VR uses fantasy worlds, and 3D real-life virtual situations with high ecological validity are more acceptable to the children [4, 66]. In a recent randomized trial of 400 children by Khandelwal et al. [70], it was found that audiovisual distraction is superior to the “Tell Show Do” (TSD) method in the management of anxious children aged 5–8 years [71]. Likewise, with this result, the study of Nunna et al. [72] revealed a significant reduction in mean pulse rates in children who had their injection while watching cartoons under VR distraction [70]. But also, providing LA with music or 3D video glasses as distraction has been found to have an added advantage in the majority of children, as 3D video glasses proved to be superior to music [71]. The use of another relaxation exercise, “The Bubble Breath” (the art of deep breathing, to inhale deep breaths through the stomach and slowly exhale as if blowing air out until asked to stop), has been found beneficial in decreasing the pain perceived during maxillary buccal infiltration of LA in 7–11-year-old children and may be used as a technique to reduce procedural pain [67]. All in all, the American Association of Pediatric Dentistry, recognizing the importance of managing children’s pain during dental procedures, has created a guide to relaxation techniques for dental care. Among other things, their manual reports the use of “communication and communicative guidance” which includes positive pre-visit imagery, direct observation, TSD, ask-and-tell, voice control, nonverbal communication, positive reinforcement and descriptive praise, destruction, memory restructuring, desensitization to dental setting and procedures, enchanting control, parental presence, absence, sensory adapted dental environments, animal-assisted therapy, and picture exchange communication system [68]. Nevertheless, the strongest results were found in a study of 60 students [73], in which both groups received either the use of a smartphone application or of a more conventional behavioral technique (TSD, modeling, voice control) to manage stress before dental procedures. The results showed reduction in all anxiety parameters; however, the reduction in anxiety parameters was almost double in the smartphone application group as compared to conventional behavior management techniques [73].
Future Trends
Stress is an inevitable reality of life. But stress is not always adverse. It is a natural, physiological response that alerts the organism to the possibility of danger, thus triggering the fight-or-flight response to protect and preserve the organism. Stress can increase awareness in challenging or dangerous situations [1]. Everyone responds to stress differently; identifying individual stressors is of paramount importance. In most cases, the sources of stress are obvious to identify peer relationships, poor work or socioeconomic environment, health concerns, academic achievement, or the existence of a psychiatric or medical condition, for instance. In other cases, finding the root of stress and anxiety may be more challenging. Research consistently shows that relaxation techniques are useful in reducing stress; they are the child’s ally to help with everyday stressors and stress management.
As relaxation techniques gain more and more popularity, it appears that we are moving toward integrating them into our daily lives, both for adults and children. The use of electronic stress tracking devices, such as smart watches, measures stress levels using a variety of data like heart rate, blood oxygen, or moisture levels on the skin. Relaxation and meditation applications are free or affordable and can be downloaded on different devices used by children and adolescents. The widespread use of technology can be a new ally in teaching relaxation techniques and measuring their impact. Based on the substantial gains documented in in-class stress reduction programs, we can safely assume that it will be the first intervention to prevent and reduce stress [66].
Conclusions
“That the birds of worry and care fly over your head, this you cannot change; but that they build nests in your hair, this you can prevent.” - Chinese Proverb
Ancient wisdom and modern science coincide in that we cannot abolish stress from human life; research shows that there are specific techniques that alleviate stress and promote mental health, both in children and adults. This review supports the idea that the use of techniques can reduce stress levels of the organism, thereby reducing the symptoms of the disease. Relaxation techniques are simple to learn and use. Adults can demonstrate them to children and adolescents and encourage them to use these techniques as needed. When teaching stress management to children, we must take into account Delgado’s premonition that “one important fact to remember is that our comments are only helpful if they make sense to the child” [15]. Therefore, an important element for a successful intervention is the careful selection of appropriate techniques that meet the needs of the child. Overall, as technology and life evolve, research offers access to these techniques in a way that our youngsters have become accustomed to, that is, using technology and applications. As the use of relaxation techniques is the predominant method for achieving stress and anxiety management, improving focus and academic achievement, and promoting social skills, we adults need to be careful to offer them in a way that “makes sense” to children and adolescents.
This article aims to present the stress management techniques of children and adolescents in as much detail as possible, starting from the dominant perspective of the past, moving on to the current use of the techniques, and reaching into the possible future. It was deemed appropriate to follow a freer and more narrative form of writing while maintaining the scientific review of the literature, as this is an issue that may be of interest to both academic and health care professionals (pediatricians, developmental specialists) or other specialists such as special education teachers and occupational therapists or even parents.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
This review has not received any funding.
Author Contributions
Liza Varvogli and Triantafillia Zisopoulou contributed equally to this review.