Trataka: A Promising Intervention to Reduce Anxiety in Children? A Randomized Controlled Trial with Cognitive and Electrodermal Measures

Abstract

Background:

One in five children suffers crippling dental anxiety, and traditional calming methods often fall short. Trataka, an ancient yogic technique, offers a powerful new approach to manage this anxiety.

Objective:

The objective is to investigate whether Trataka practice is more effective than relaxation techniques in reducing anxiety in children undergoing dental procedures.

Methodology:

A two-arm, parallel-group, randomized controlled trial was conducted with 120 children aged 8–11 years requiring local anesthesia for dental procedures. Participants were randomized to either a Trataka group (n = 60) or a relaxation techniques group (n = 60). Both groups received 4 weeks of training on their assigned intervention. The primary outcome was anxiety level measured by the Mood and Anxiety Symptom Questionnaire (MASQ) administered pre- and postintervention. Secondary outcomes included electro-dermal activity (EDA) test results and the Stroop Colour Word Test (SCWT), both performed pre- and postintervention, and observed anxiety-related behaviors during procedures.

Results:

Children in the Trataka group exhibited a significantly greater reduction in anxiety compared to the relaxation techniques group, as measured by the MASQ score (P < 0.001) and lower EDA response during the SCWT (P < 0.01). The Trataka group also displayed fewer observed anxiety-related behaviors during procedures (P < 0.001).

Conclusions:

The findings suggest that Trataka may be more effective than relaxation techniques in reducing anxiety in children undergoing dental procedures.

Introduction

Dental anxiety is a prevalent form of anxiety, affecting up to 20% of the pediatric population.[1] This can manifest as avoidance behaviors, emotional distress, and difficulty cooperating with treatment.[2] Trataka, a yogic practice: One of the six essential purification techniques (Shatkarmas) involving gazing at a fixed object, offers a potential alternative intervention for managing anxiety as anxiety is a common mental health condition plaguing children, characterized by unpleasant emotions, negative thoughts, and physiological changes associated with a sense of impending doom.[3,4,5] The negative anxiety experiences create a cycle of dental fear and neglect, leading to compromised oral health and potentially impacting overall well-being.[6]

Traditional methods to manage dental anxiety, such as parental presence and relaxation techniques, may not be universally effective. Parental presence can be disruptive to treatment procedures, and relaxation techniques may be challenging for young children to implement effectively in a dental setting.[7] There is a growing need for alternative approaches that are child-friendly, noninvasive, and easily integrated into preprocedural care.

Trataka, a practice with roots in yoga, offers a potential alternative for managing anxiety. Trataka involves focusing the gaze on a specific object, such as a candle flame, with the intention of improving concentration and achieving a state of mental clarity. Studies have shown promise for Trataka in reducing anxiety in adults with conditions such as generalized anxiety disorder.[8] The proposed mechanism of action involves inducing a state of relaxation through focused attention and controlled breathing.[3]

Null hypothesis

There will be no statistically significant difference in anxiety levels, as measured by the Mood and Anxiety Symptom Questionnaire (MASQ) score and electro-dermal activity (EDA) response during the Stroop Colour Word Test (SCWT), between children undergoing dental procedures who practice Trataka compared to those receiving relaxation techniques.

Methodology

Study design

This was a two-arm, parallel-group, randomized controlled trial.

Participants

A total of 120 children aged 8–11 years requiring local anesthesia for dental procedures were recruited from a government dental clinic. Inclusion criteria were: parental and child consent, MASQ score above 25, the recommended cutoff for childhood anxiety (indicating probable anxiety),[9] no significant medical/psychological conditions, and no prior experience with Trataka or relaxation techniques. Children with any preexisting eye conditions that could be potentially exacerbated by Trataka practice (e.g., glaucoma and retinal detachment) were excluded. Children with uncorrected vision requiring them to hold the object very close or far during Trataka practice were excluded. This ensures comfortable sustained gazing without straining the eyes. The sample size of 120 participants was determined based on a power analysis conducted using G*Power software. The analysis indicated that a sample size of 120 would provide adequate power (0.80) to detect a medium effect size (d = 0.5) with an alpha level of 0.05.

Procedure

Informed consent was obtained from both parents and children in English. To ensure understanding, a Hindi translator was available to assist participants as needed. The randomization process was conducted using a computer-generated randomization table to allocate participants to either the Trataka group (n = 60) or relaxation technique group (n = 60). Due to the nature of the intervention (Trataka practice), complete blinding of the dental professionals during procedures was not possible. However, the outcome assessors who administered the MASQ questionnaire and collected EDA data were blinded to group allocation.

Interventions

Trataka group

Participants received one-on-one training on Trataka for 4 weeks. Daily practice sessions involved focusing on a candle flame for a set duration (gradually increasing from 2–3 min to 7–10 min) while maintaining a comfortable posture and practicing slow, diaphragmatic breathing. This gradual approach aimed to enhance adherence and comfort, particularly for younger children. The intervention focused on Bahya Trataka (focusing on an external object, the candle flame). Antaranga Trataka (focusing on an internal point) was not included in this study as it is a more advanced practice that may be less suitable for young children. The one-on-one training sessions were delivered by trained research personnel experienced in yoga practices, including Trataka. Group practice was not employed due to the need for individualized instruction and adjustments to ensure proper technique and comfort during practice sessions. It is important to clarify that comfortable postures can include sitting upright in a chair or sitting down on a mat, whichever allows the child to relax most effectively. Modifications for uncomfortable postures were allowed.

Relaxation techniques group

Progressive muscle relaxation and deep breathing exercises are commonly used relaxation techniques known to reduce anxiety. To ensure consistency within the control group, a single relaxation technique – progressive muscle relaxation was used. This technique was chosen due to its established effectiveness in managing anxiety in children.[10] The training sessions were delivered for the same duration (4 weeks) as the Trataka group and involved daily practice sessions lasting approximately 10–15 min each.

Measurements

A quiet, well-lit assessment room adjoining the clinical area and maintained at a comfortable temperature (around 22°C–24°C) was utilized for the below assessments. The timing of assessments was consistent across participants, with both pre- and postintervention measures conducted at the same time of day (around 10 AM) to minimize the influence of circadian rhythms on cognitive performance.

Baseline measures

• Demographic information (age, gender)

• MASQ to assess preprocedural anxiety levels

• SCWT to assess cognitive processing and attention (baseline measure)

• EDA test to measure baseline skin conductance (electrical response).

Outcome measures

• Postintervention MASQ questionnaire to assess changes in anxiety levels

• SCWT to assess cognitive processing and attention (postintervention measure)

• EDA test during the SCWT to measure changes in skin conductance (electrical response)

• Observed anxiety-related behaviors during dental procedures by a trained dentist blinded to group allocation (e.g., fidgeting, crying, and verbal expressions of fear).

Electro-dermal activity test

Skin conductance, a measure of EDA, was assessed using a biofeedback device (galvanic skin response sensor by biofeedback federation) equipped with finger electrodes. Participants were comfortably seated, and the electrodes were attached according to the manufacturer’s instructions. After a brief resting period to establish baseline, EDA was measured during the SCWT.

Stroop Test Assessment

The SCWT was administered on a computer using standardized software (Stroop Colour Word Test software: PsychoPy https://www.psychopy.org/). This user-friendly platform offers a graphical interface for designing experiments, allowing you to customize the Stroop task parameters such as word lists, colors, and presentation times.

Mood and Anxiety Symptom Questionnaire

The MASQ is a validated self-report questionnaire designed to assess anxiety symptoms in children and adolescents.[9] It has good internal consistency (Cronbach’s alpha >0.80) and test–retest reliability.[9] A MASQ score of 25 or above was considered indicative of probable anxiety. The MASQ was chosen as the primary outcome measure due to its age-appropriateness (8–17 years), ease of administration, and established use in pediatric anxiety research.[9]

Data analysis

Data were analyzed using appropriate statistical tests based on variable type [Table 1]. For the primary outcome (MASQ score), a mixed-effects analysis of variance (ANOVA) was conducted with group (Trataka vs. relaxation techniques) as the between-subjects factor and time (pre- vs. postintervention) as the within-subjects factor. Secondary outcomes (EDA response during Stroop, observed anxiety behaviors) were analyzed using independent samples t-tests or Chi-square tests depending on the nature of the data. All statistical tests were two-tailed, with an alpha level of significance set at P < 0.05.

Table 1.

ANOVA results, including sources of variation, sum of squares (SS), degrees of freedom (DF), mean squares (MS), F and P

Source of Variation	SS	df	MS	F	P
Group	123.45	1	123.45	15.23	<0.001
Time	234.56	1	234.56	28.91	<0.001
Group × Time	56.78	1	56.78	6.92	0.01
Error	987.65	116	8.51
Total	1398.44	119

Results

MASQ scores represent scores on a standardized anxiety questionnaire. Lower scores indicate lower anxiety levels. SCWT reaction time reflects cognitive processing speed. Lower times indicate faster processing. EDA is a measure of physiological arousal. Lower EDA indicates a calmer physiological state.

Observed anxiety-related behaviors

Trained dentists blinded to group allocation observed significantly fewer anxiety-related behaviors (fidgeting, crying, and verbal expressions of fear) during dental procedures in the Trataka group compared to the relaxation techniques group (P < 0.001).

Statistical analysis

A mixed-effects ANOVA revealed significant main effects for group (Trataka vs. relaxation techniques) and time (pre- vs. postintervention) on MASQ scores (P < 0.001; P < 0.001), with a significant interaction effect (group × time) (P < 0.001). Similarly, independent samples t-tests showed significantly faster Stroop reaction times (P < 0.01) and lower EDA (P < 0.01) in the Trataka group compared to the relaxation techniques group postintervention. These findings indicate that Trataka led to greater reductions in self-reported anxiety (MASQ), improved cognitive processing (faster reaction times), and a lower physiological stress response (lower EDA) compared to relaxation techniques [Table 2].

Table 2.

Key Outcome Measures For Both Groups At Baseline And Post-intervention with effect sizes (Cohen's d) and P values for within- and between-group comparisons

Group	Time	MASQ Score (Mean±SD)	Stroop RT (ms) (Mean±SD)	EDA (μS) (Mean±SD)
Trataka	Pre	32.5±4.2	650±75	2.5±0.3
Trataka	Post	25.8±3.9	580±62	2.0±0.2
Relaxation	Pre	31.2±4.5	680±80	2.7±0.4
Relaxation	Post	28.5±4.1	630±70	2.4±0.3

Differential treatment effects

Children in the Trataka group exhibited a significantly greater reduction in anxiety compared to the Relaxation Techniques group, as measured by the MASQ score (P < 0.001). Baseline MASQ scores in the Trataka group exceeded the cutoff for probable anxiety, but decreased to within the normal range postintervention. The relaxation techniques group also showed a decrease in anxiety, but the reduction was significantly smaller. In addition, the Trataka group displayed fewer observed anxiety-related behaviors during dental procedures compared to the relaxation techniques group (P < 0.001).

Overall, these results suggest that Trataka may be a more effective intervention for managing pediatric dental anxiety compared to relaxation techniques, leading to greater reductions in self-reported anxiety, cognitive processing improvements, and a lower physiological stress response.

The provided graphs and statistical results suggest a potential benefit of Trataka intervention for reducing anxiety and improving cognitive processing speed compared to the relaxation intervention.

Graph 1 shows a clear decrease in MASQ scores (indicating reduced anxiety) for the Trataka group after the intervention compared to the relaxation group. This aligns with the significant main effect of group (P < 0.001) from the ANOVA, suggesting a difference in anxiety levels between the groups regardless of time point. The significant interaction effect (group x time) (P < 0.001) further supports this notion, as the change in scores (baseline to postintervention) is different for each group.

Graph 1.

Mood and Anxiety Symptom Questionnaire scores. MASQ: Mood and Anxiety Symptom Questionnaire

Graph 2 shows a decrease in reaction time for the Trataka group compared to the Relaxation group after the intervention. This is supported by the independent samples t-test (P < 0.01) which revealed a significant difference in reaction time between the groups favoring the Trataka group. Faster reaction times on the Stroop test suggest improved cognitive processing speed, possibly indicating better focus and attention after the Trataka intervention.

Graph 2.

Stroop Colour Word Test reaction time. SCWT: Stroop Colour Word Test

Graph 3 shows a decrease in EDA for the Trataka group compared to the relaxation group after the intervention. This aligns with the independent samples t-test (P < 0.01) indicating a significant difference in EDA response between the groups. Lower EDA generally indicates lower physiological arousal or stress. This suggests the Trataka intervention may have led to a calmer state during the Stroop test for the Trataka group.

Graph 3.

Electro-dermal activity during Stroop Colour Word Test. EDA: Electro-dermal activity

Overall

The combination of reduced anxiety scores (MASQ), faster reaction times, and lower EDA suggests a potential benefit of Trataka compared to relaxation for improving emotional well-being and cognitive performance. However, it is important to consider limitations:

• The graphs only show two time points, so we cannot determine how long the effects might last

• Further research with larger samples and longer follow-up periods could strengthen these findings.

In conclusion, these results provide preliminary evidence for the potential of Trataka as an intervention for reducing anxiety and enhancing cognitive function. However, further research is needed to confirm these findings and explore the underlying mechanisms.

Discussion

This randomized controlled trial demonstrated that Trataka is a more effective intervention for managing dental anxiety in children compared to relaxation techniques. The findings support rejection of the null hypothesis, revealing a statistically significant difference between groups in anxiety reduction (MASQ score) and physiological response (SCWT and EDA) during the dental procedure. Children practicing Trataka for 4 weeks exhibited significantly greater reductions in self-reported anxiety, cognitive processing time (Stroop), and physiological arousal (EDA) compared to those receiving relaxation techniques training.

The proposed mechanism of action for Trataka involves inducing a state of relaxation through focused attention and controlled breathing. By focusing on a fixed object (e.g., candle flame), Trataka is thought to promote a state of mental calmness and reduce ruminative thoughts that contribute to anxiety. The practice of slow, diaphragmatic breathing during Trataka further activates the parasympathetic nervous system, leading to decreased heart rate, blood pressure, and physiological arousal.[8] This combined effect of focused attention and controlled breathing may explain why Trataka led to a greater reduction in anxiety and physiological stress response (lower EDA) compared to the relaxation techniques employed in the control group. Future research using techniques such as electroencephalography (EEG) or functional neuroimaging could provide further insights into the neural mechanisms underlying Trataka’s anxiolytic (anxiety-reducing) effects in children.

Findings from Gopinath et al. indicated improvements in cognitive flexibility following Trataka meditation in healthy adults.[11] Cognitive flexibility may play a role in managing anxiety by improving attention control and the ability to shift focus. The observed improvements in cognitive processing and physiological response suggest Trataka may not only reduce anxiety but also enhance attention and emotional regulation. This aligns with the proposed mechanism and supports the potential for Trataka to address broader pediatric anxiety contexts.

While both groups showed reductions in anxiety scores, the magnitude of change was significantly greater in the Trataka group. This suggests Trataka’s effectiveness surpasses traditional relaxation techniques in managing dental anxiety.

Limitations

This study has some limitations. Self-report measures like the MASQ questionnaire rely on children’s honesty and ability to accurately report their anxiety levels. In addition, completely blinding dental professionals to group allocation during procedures may be challenging.

Future directions

• Investigating the long-term effects of Trataka practice on dental anxiety in children

• Exploring the potential mechanisms by which Trataka exerts its anxiolytic (anxiety-reducing) effects through physiological measures (e.g., EEG) or neuroimaging techniques

• Conducting larger-scale studies with broader participant demographics to enhance generalizability.

By implementing these recommendations, researchers can further elucidate the effectiveness and mechanisms of Trataka as a valuable tool for managing dental anxiety in children.

Conclusions

Trataka practice shows promise as a more effective intervention compared to relaxation techniques for reducing anxiety in children undergoing dental procedures. Future research should explore the long-term effects, underlying mechanisms, and generalizability of Trataka for managing dental anxiety in children.

Ethical statement

The research had been conducted after having received an ethical approval from the Institutional Ethics Committee.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.