452 Child Health Psychology
(Hurtig & Viera, 1986), and depression related to a perceived
loss of control (Brown, Armstrong, & Eckman, 1993). Ado-
lescents with SCD seem to be especially vulnerable to distur-
bances in behavior, social adjustment, and dissatisfaction
with body image (Brown, Kaslow, et al., 1993; Gil, Williams,
Thompson, & Kinney, 1991; Lemanek et al., 1995).
Intermittent, unpredictable, and, at times, extreme pain re-
lated to vaso-occlusive crises and impacting quality of life is
the most common symptom of SCD. As a result, pain man-
agement, both in the hospital and at home, is a focal issue for
children with SCD, their families, and their health care
providers. There is a solid medical literature to guide phar-
macological approaches to pain management in children with
SCD (see Embury, Hebbel, Mohandas, & Steinberg, 1994).
However, there are few well-controlled studies examining
nonpharmacological approaches to pain management, partic-
ularly for children with SCD. Similar to the literature on pro-
cedure-related pain, CBT has the most empirical support in
the management of disease-related pain but the literature on
disease-related pain is less developed than that concerning
procedure-related pain.
Gil and her colleagues (2001) compared the ef“cacy of a
coping skills intervention with standard care to address
painful episodes in children with SCD (n46). The inter-
vention comprised one session of face-to-face instruction in
relaxation, imagery, and self-talk followed by daily practice
supported by an audiotape. Results at the end of the interven-
tion supported the coping skills training in terms of reducing
pain sensitivity and negative thinking. However, at one-
month follow-up, only effects for increased coping attempts
remained, and there were no between-group differences on
measures of pain and health care contact. Other studies have
shown an impact of cognitive-behavioral interventions on
pain in SCD. In a study conducted by Dinges et al. (1997),
standard treatment for SCD-related pain was compared with
standard treatment plus self-hypnosis training. Thirty-seven
children, adolescents, and adults with SCD participated in a
group-based training in self-hypnosis over an 18-month pe-
riod. Family members were invited to participate in the
groups. From results based primarily on daily pain diaries
completed by the participants, the frequency of pain episodes
was reduced and the number of pain-free days was increased.
Medication use decreased for those who had more days free of
pain as a result of the intervention. The intervention seemed
most effective for milder pain episodes. There was no effect
on absenteeism from work or school. In an earlier study,
Cozzi, Tryon, and Sedlacek (1987) reported on the effective-
ness of relaxation training, assisted by biofeedback and ad-
ministered by audiotape. Results with a small sample of eight
children and adolescents with SCD found improvement in
only self-reports of pain-related symptoms but not in more
objective measures of pain such as emergency department
visits or hospitalizations. No follow-up data were collected.
The studies reviewed here, and those using samples of
adults with SCD (e.g., Zeltzer, Dash, & Holland, 1979), pro-
vide quali“ed support for the ef fectiveness of cognitive-
behavioral approaches in reducing SCD-related pain and
improving quality of life, as is the case for such interventions
in other pediatric groups (Walco, Sterling, Conte, & Engel,
1999). Replication of these “ndings with pediatric samples
using standardized interventions and control groups is neces-
sary (Walco et al., 1999). Furthermore, issues speci“c to
SCD, such as cognitive functioning and anxiety and depres-
sion, must be considered to assess utility for painful episodes
(Gil et al., 2001). In summary, •evidence for the generaliza-
tion, maintenance, practicality, and cost-effectiveness of
these interventions will be an important future goalŽ (Manne,
1999, p. 148).Recurrent Headache. Recurrent headache in children
involves discrete and unpredictable pain episodes that may sig-
ni“cantly impact psychosocial functioning. About 25 of every
1,000 school-age children experience recurrent headache;
more than 1 million children experience migraine speci“cally
(Holden, Rawlins, & Gladstein, 1998). Diagnosis of headache,
which has typically been made as migraine (autonomic ner-
vous system symptoms) or tension headaches (muscular ten-
sion), may also be conceptualized on a continuum as children
and adolescents often experience more than one type of
headache (Holden, Deichmann, & Levy, 1999). Assessment
and diagnosis of recurrent headache is made through history-
taking and carefully selected laboratory tests. As in the case of
pediatric pain more generally, a pain diary can be a useful tool
in the assessment of headache (McGrath & Larsson, 1997).
Precise diagnosis is hampered by a lack of clear underlying
physiology and the lack of reliability of children•s reports.
Individual and family factors must be considered in de-
signing interventions for children with recurrent headache
given evidence that psychosocial factors play a role in their
onset, maintenance, and exacerbation. Holden et al. (1998)
reported that gender and perceived control in”uence how
adolescents cope with recurrent headache. Active coping was
used by males who perceived control over their headaches
and by females who did not perceive control. Problem solv-
ing, seeking medical help, using social support, cognitive re-
structuring, and relaxation were viewed as most helpful.
Labbe (1999) pointed to research showing the impact of fam-
ily context; parental modeling of coping with headache is an
important issue as may be positive reinforcement children re-
ceive for reports of headache pain.