450 Child Health Psychology
TABLE 19.2 Cognitive and Behavioral Interventions for
Procedural Pain
Technique DescriptionPreparation Providing step-by-step procedural information
(what will be done) and sensory information
(what it may feel like) to help the child develop
realistic expectations for the procedure.
Desensitization Gradually exposing the child, in hierarchical
fashion, to stimuli associated with the proce-
dure (through imagery or in vivo exposure).
Positive self-statements Coaching children to use simple statements
(which focus on self-ef“cacy and realistic
appraisal of the situation) that they can repeat
to themselves just before or during the
procedure.
Reframing beliefs Helping the child to realistically appraise
Changing memories the situation and his/her own ability to cope
with it to increase self-ef“cacy
and reduce anticipatory anxiety.
Imagery Child focuses intensely on a vivid pleasant
mental image (with auditory, visual, and
kinesthetic components), which is guided by
the therapist. Like distraction, it takes the
child•s focus away from the procedure.
Relaxation A combination of progressive muscle
relaxation and deep, controlled breathing is
often used to reduce physiological arousal and
anxiety before and during procedures.
Modeling/ Observation of another child or an adult
Behavioral rehearsal undergoing a mock procedure while
demonstrating positive coping behaviors
(e.g., a video). The child can then practice
these strategies by rehearsing with the
therapist, staff, or parent.
Distraction Engaging the child in cognitive activities or
behaviors that divert attention from the painful
procedure. Blowing bubbles, watching a video,
listening to a story, or counting may be
appropriate depending on the developmental
level of the child.
Positive reinforcement Speci“c labeled praise (•I like how well you
stayed stillŽ) and tangible rewards (e.g.,
stickers) after completing a painful procedure.
Successful interventions for procedure-related pain and
anxiety must be individualized to the child•s developmental
level, the invasiveness and duration of the procedure, the
child•s medical status, and the context in which the procedure
occurs (Anderson, Zeltzer, & Fanurik, 1993). The develop-
mental level of the child is important in determining under-
standing of the pain experience and response to speci“c
intervention techniques. Many of the cognitive and behav-
ioral techniques described earlier are useful for children from
preschool through adolescence, but must be tailored to the in-
terests and abilities of the individual child. For 2- to 3-year-
old children, pop-up books or simple electronic toys that
make animal noises, say a sentence, or play a tune when the
child touches the picture may be effective distractions
(Dahlquist, 1999). A 9-year-old may “nd a computer game or
video distracting from a painful procedure, whereas an older
adolescent may be able to use cognitive distractors (e.g., im-
agery, counting ceiling tiles, or focusing on a particular ob-
ject in the room). Relaxation techniques can also be tailored
to the child•s level of development. Young children can be
taught to take deep breaths during a procedure and to focus
on inhaling and exhaling each breath slowly using bubble
blowers or noise makers. Older children and adolescents may
bene“t from techniques such as progressive muscle relax-
ation (Anderson et al., 1993).
Children do not use distraction and other pain manage-
ment techniques without guidance and prompting by adults
(Dahlquist et al., 1986). Parents, however, are often anxious
not only about their child•s distress, but also about their own
ability to comfort their child through the medical procedure.
Parents, as well as health care providers, may also be un-
aware of how they are responding when the child is dis-
tressed and of the impact their reactions have on the child.
During painful medical procedures, anxious and distressed
parents can appear angry at their child for crying, scolding
the child or threatening punishment if he or she does not
cooperate (Anderson et al., 1993; Dahlquist, 1999). Others
plead with their child, repeating the same vague commands
over and over in a misguided attempt to soothe their child
(e.g., •Please relaxŽ). Several studies have shown that adult
criticism, vague commands, apology, agitation, and reassur-
ing statements do not appear to be helpful for children
undergoing painful medical procedures and may actually
contribute to increased distress (Dahlquist, Power, &
Carlson, 1995; Dahlquist, Power, Cox, & Fernbach, 1994).
Thus, an important target for interventions is to decrease the
amount of anxiety and distress experienced by parents and
communicated to the child.
In the past decade, researchers have begun to recognize
the in”uence of parents• behaviors and beliefs on child dis-
tress and anxiety and have attempted to measure these di-
rectly. Successful interventions that rely on relationships
among the child, family, and staff have been developed. Parent
and staff report of child behavioral distress/cooperation
have been used as measures of treatment outcome (e.g.,
Manne et al., 1990; Powers, Blount, Bachanas, Cotter, &
Swan, 1993). These studies include observations of child
coping behaviors (e.g., breathing, imagery) and parent/
staff coping-promoting behaviors (e.g., prompting the child
to use certain coping strategies, distracting the child with talk/
activities), which generally have been found to improve with
the use of cognitive-behavioral interventions.