COMMENTARY

Overcoming Injection Fears: Helping Kids Learn to Be Brave

Katherine Dahlsgaard, PhD

Disclosures

February 18, 2014

Editorial Collaboration

Medscape &

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Hi. I'm Dr. Katherine Dahlsgaard. I am a licensed psychologist and lead psychologist of the Anxiety Behaviors Clinic here at Children's Hospital in Philadelphia. Today, I am going to talk about children with injection fears and phobias, what healthcare providers can do to prepare children for a successful injection, as well as what we can do to help parents prepare their children at home for a successful shot experience.

Estimates vary, but it appears that about 2%-8% of children and adolescents report full-blown injection phobias: an extreme fear combined with what is known as functional impairment that gets in the way or messes things up for the kid. I hear examples of parents putting off the human papilloma vaccine, for example, because their child is so afraid of shots, or putting off dental work that is necessary because their child is resisting it because they don't want Novocain (procaine) or a shot.

Well over half of children walking into your office are going to have mild-to-moderate fears of injections. That can cause functional impairment in your office as well because if you have screaming kids or kids that are breaking down in the waiting room, they are kind of gumming up the works in your practice. So it really is a good idea to prepare kids so that they have a successful experience and your office also is successful in providing shots to kids. What I do in the office is what is known as exposure: That is the active ingredient in the treatment for any phobia.

Exposure can be done in the office, but it can also be done by parents both at home and in the doctor's office. I usually recommend 5 basic strategies for kids with mild-to-moderate fears who don't need full psychological treatment, but they are all basically exposure-based.

Number one is psychoeducation -- educating kids about shots. It is incredibly important because most kids only encounter a needle maybe once or twice a year, and they have a lot of misconceptions about shots. They think the needle is going to be "this big," and they think it's going to hurt terribly, and what they need is good psychoeducation. A good resource for you to recommend to parents or to allow kids to watch in your waiting room if you have computers is a gorgeous video made by The Jim Henson Company called Sid, the Science Kid: Getting a Shot, You Can Do It! . It is 28 minutes long and available on YouTube. It is a wonderful instructional video with songs and dancing that basically tells kids all they need to know about why shots are needed, what actually happens, how big the needles are, and it also gives them a brave song to sing.

The second thing I recommend to parents and to kids is that they look at some role models, which is other peers getting shots and being brave. And there are plenty of really great videos on YouTube of teenagers and of children of all different races receiving shots and acting brave while they get the shots, not showing a lot of distress. I have kids in my office watch those over and over and over. Once is not enough. Watching a role model, a peer you can relate to get a shot -- and watching that video over and over again, they're usually about 2 minutes long -- until the anxiety of watching it dissipates is great. It is both exposure habituation and providing another kid to emulate. The child will realize it's possible to sit still for a shot.

The third thing I recommend is teaching kids something about brave body, and brave body is the opposite of scared body. Most kids who are about to get a shot insist on sitting in their mother's lap, and it becomes a struggle. What I do with kids is I teach them very clearly what is expected for brave body. I say, "If you act brave, you will feel more brave." I show them what brave body looks like: shoulders back, arm in my lap and relaxed, I roll up my sleeve like I don't have a care in the world, I look away, and I don't sit in my mom's lap. I do recommend that. Mom sits in front of the kid for that encouragement, but the child sits by herself when she is getting the shot.

The fourth thing I recommend is a coping card, and this is a card that children write out in advance that they read to help them have courage during the shot. It also helps to distract them. Remember I said that they shouldn't sit in mom's lap? Mom should sit in front of them. I suggest during the shot that the child read the coping card to mom or to the parent that is accompanying the child so that they are distracted, saying a brave thing that they will come up with on their own, and are also looking at the card and not the injection site. An actual coping card that I have -- this is an actual child who was very terrified of shots and with whom the card was very successful: "It will hurt for a second, but then it will be over. Millions of people have gotten shots before me, and this is no different. I can do it." And she simply read it to her mom over and over during the course of the shot she received.

Finally, I recommend that parents and kids work out a good plan. A good plan is written down, the child describes how he or she is going to act during the shot, and both the parent and child sign. It should be something like, "I'm going to do brave body," "I'm going to read my coping card," and "I'm going to look at Dad while I read the coping card." And if the child does those things, immediately after the shot, the child can go get a reward -- either go out for ice cream immediately or go to a toy store for a small toy. I make it clear to parents that they're not rewarding their child for not being scared. Rather, they're rewarding their child for engaging in these coping behaviors. Being brave is not not being scared. It is being scared but dealing with it in your own way. I think that is what should be rewarded.

Those are my recommendations, and I mentioned some resources that you can find online.

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