Selective Interventions 449Flowing from the biobehavioral model, Varni and his col-
leagues (1995) recommend that interventions move beyond
narrowly focused strategies aimed at decreasing reports of
pain. To enhance effectiveness, interventions must target pain
perception, pain behaviors, and the intervening variables
(Varni, 1999; Varni et al., 1995). Modifying pain perception
involves self-regulatory mechanisms such as self-hypnosis,
meditative breathing, progressive muscle relaxation, and
guided imagery. Manne (1999) emphasizes the need to ad-
dress cognitive appraisal of painful procedures as part of in-
terventions for procedure-related pain by helping children
and their parents to perceive the procedure as less threaten-
ing. Furthermore, by targeting intervening variables such as
coping strategies, children and their parents may be sup-
ported in managing adaptively aspects of treatment or of the
illness, thereby improving functional status outcomes as well
as reducing pain perception. Coping strategies such as seek-
ing social support, active behavioral distraction, problem
solving, and self-instruction or self-talk may be most adap-
tive for children with chronic medical conditions.
To this point, the role of the family in pain perception and
behaviors and in functional status outcomes has not been
clearly delineated. While many disease-related pain interven-
tions invite family participation (e.g., Dinges et al., 1997), the
family•s role is not addressed directly. Models for intervening
in procedure-related pain are useful because they integrate
family. Varni et al. (1995) summarize this literature by noting
that parent appraisals of the illness and of pain, parent cop-
ing, and family functioning will in”uence parent interactions
with their children during painful procedures (and painful
crises) as expressed through parent distress and anxiety-
promoting behaviors. These parent behaviors will, in turn,
impact children•s coping and children•s pain perception and
behaviors. As such, parent or family factors must be ad-
dressed as an integral element of effective interventions.
Interventions for Procedure-Related Pain
Childhood cancer is life threatening and experienced by chil-
dren and their parents with fear, horror, and helplessness
(Kazak, Stuber, Barakat, & Meeske, 1996; Smith, Redd,
Peyser, & Vogl, 1999). It is not a discrete trauma but is repet-
itive (diagnosis and treatments) and chronic (in the form of
follow-up visits, medical late effects, and the risk of recur-
rence or second cancers; Nir, 1985; Smith et al., 1999;
Stuber, Kazak, Meeske, & Barakat, 1998). Given this trau-
matic experience, short- and long-term responses to child-
hood cancer can be understood as trauma responses. Studies
have found that mothers and fathers of survivors of childhood
cancer report signi“cantly more symptoms of posttraumatic
stress than parents of healthy children dealing with moder-
ately severe stressors (Barakat et al., 1997; Kazak et al.,
1997). Young adult survivors, but not child or adolescent sur-
vivors, report signi“cant symptoms of posttraumatic stress
(Barakat et al., 1997; Rourke, Stuber, Hobbie, & Kazak,
1999; see Butler, Rizzi, & Handwerger, 1996, for an excep-
tion). Currently, interventions focus on reducing the traumatic
nature of cancer and its treatment during the treatment phase
in addition to providing support as families move off treat-
ment and into the survivor phase (Kazak et al., 1999).
Children with cancer must endure repeated invasive and
painful medical procedures such as bone marrow aspirates,
biopsies, and lumbar punctures, as these are integral compo-
nents of cancer diagnosis and treatment. Studies have shown
that children with cancer consider painful procedures as the
most unpleasant and feared aspect of cancer treatment
(Fowler-Kerry, 1990). The associated pain and distress does
not appear to decrease with repeated procedures and may
worsen if pain is not adequately managed. For example, a
child who has been sensitized by a previous painful procedure
that was not successfully managed may have anticipatory anx-
iety to the point of noncompliance or refusal to cooperate with
future procedures (Miser, 1993). Our research has shown that
child survivors of cancer report that getting shots and needles
are among the most recalled and upsetting aspects of cancer
(Kazak et al., 1996). Parents, too, report that seeing their child
in pain results in fear, horror, and helplessness (Kazak et al.,
1996). Thus, the optimal approach to procedure-related pain
in children with cancer is critical for the well-being of the
child and family and may have long-term implications for ad-
justment. This presents a compelling clinical and research
goal that requires interdisciplinary collaboration.
In clinical practice, a number of different psychological
treatments are used for children undergoing painful medical
procedures (e.g., hypnosis, biofeedback), but the constellation
of treatments commonly referred to as cognitive-behavioral
therapy has been the most widely studied (e.g., Chen, Joseph,
& Zeltzer, 2000; Powers, 1999). In his review of literature,
Powers (1999) illustrated that cognitive-behavioral interven-
tions are a well-established treatment for reducing behavioral
distress and anxiety in children undergoing painful medical
procedures. Typical components of a cognitive-behavioral
treatment package often include breathing exercises, distrac-
tion, imagery, positive self-statements, modeling, behavioral
rehearsal/role play, and positive reinforcement for using cop-
ing skills or lying still. Active direction from a • coachŽ (e.g.,
psychologist, medical staff, nurse, or parent) is another com-
mon component of CBT. As these approaches are well-known
and described in detail elsewhere, we have provided brief de-
scriptions of these techniques in Table 19.2.