Selective Interventions 451Researchers have also begun to investigate the impact of
children•s prior experiences and temperament on treatment
ef“cacy. Chen, Craske, Katz, Schwartz, and Zeltzer (2000)
evaluated the relationship between pain sensitivity and chil-
dren•s distress during lumbar punctures to determine whether
pain sensitivity moderates children•s responses to a brief
cognitive-behavioral intervention. This study is unique and
important because it examined temperament as a predictor of
children•s response to an intervention for acute procedural
distress. Among children who received no intervention, those
with high pain sensitivity showed greater increases in staff-
rated distress, systolic blood pressure, and parent anxiety
over time. Children with higher pain sensitivity who received
intervention showed greater decreases in these variables than
children with lower pain sensitivity. That is, intervention was
most ef“cacious for those who were most pain-sensitive.
Their results also suggest that providing pain-vulnerable chil-
dren with intervention helps reduce parent anxiety.
For psychological interventions for procedural pain to be
effectively implemented, the broader context of the attitudes
and roles of the multidisciplinary treatment team must be
considered. Effective interventions require the active engage-
ment of a triad, composed of the patient, parents/family, and
medical staff. Like parents, staff may also experience anxiety
and self-doubt when they are unable to successfully manage
a child•s pain during a procedure (Dahlquist, 1999). Their
anxiety may interfere with their ability to execute a delicate
procedure and contribute to the child•s and parents• emo-
tional distress. Thus, helping staff members manage their
own anxiety is also critical.
Many variables impact the extent to which psychological
interventions for procedure-related pain are integrated into
standard medical care. At the most basic level, the medical
team must have a clear understanding of psychological inter-
ventions and how they work to make the environment con-
ducive to using the intervention (Dahlquist, 1999). This may
entail appreciating how the relationships between the inter-
ventionist, patient, and family must be structured and main-
tained for a successful outcome (e.g., rapport building and
review of prior procedures may take some time at the outset
of the procedure). Fanurik, Koh, Schmidtz, and Brown
(1997) have suggested that the integration of pharmacologi-
cal and psychological techniques can maximize the advan-
tages of both approaches and minimize the disadvantage of
either approach used alone. They argue that when psycholog-
ical methods are introduced early in anticipation of a child•s
distress, pharmacologic intervention can sometimes be de-
layed or even avoided. Similarly, psychological interventions
may reduce short- and long-term fear responses and teach
children and families generalizable coping techniques. In
contrast, most pharmacologic approaches target primarily
pain reduction. The few studies that have examined the ef“-
cacy of combined interventions have found them to have ad-
vantages over pharmacotherapy (Kazak et al., 1996; Kazak
et al., 1998) or CBT alone (Jay, Elliott, Woody, & Siegel,
1991). Despite the established ef“cacy of both psychological
and pharmacologic treatment approaches, there remains a
puzzling lack of integration and application of these treat-
ments in practice (Zeltzer et al., 1990), and little discussion in
the pediatric literature as to how to design and implement in-
tegrated approaches.Interventions for Disease-Related PainSickle Cell Disease. The incidence of SCD in the United
States is 1 in every 400 to 500 live births for the African
American population for which sickle cell disease is most
prevalent (Hurtig, Koepke, & Park, 1989; Morgan & Jackson,
1986). SCD is a group of hematological disorders that are in-
herited, chronic, and interfere with hemoglobin production.
Complications of SCD include recurrent episodes of severe
pain in the lower extremities, back, abdomen, and chest re-
ferred to as vaso-occlusive crises, pneumococcal infections,
anemic episodes, retarded growth, splenic changes, and
strokes (Hurtig et al., 1989). Treatment may involve adminis-
tration of analgesic medication on an inpatient or outpatient
basis to control pain, prophylactic antibiotics to reduce sus-
ceptibility to infections, folic acid supplementation to help
red cell production, regular follow-up and early identi“cation
and treatment of symptoms, and blood transfusion. On aver-
age, school-age children with SCD experience at least one to
two pain episodes a month and one to two hospital admissions
and/or one emergency department visits a year (Hurtig &
White, 1986).
The unpredictable nature of SCD and its treatment, in-
cluding frequent hospitalizations and school absenteeism,
potentially threaten quality of life and disrupt psychosocial
development (Lemanek, Buckloh, Woods, & Butler, 1995).
Additionally, peer relationships may be affected by changes
in physical appearance of children with SCD, who are usu-
ally smaller in size, or by their inability to engage in normal
physical activities because of fatigue (Morgan & Jackson,
1986). Research on the adjustment of children with SCD
shows con”icting results (e.g., Brown, Kaslow, et al., 1993;
Lemanek, Horwitz, & Ohene-Frempong, 1994), but gener-
ally suggests that these children may be at risk for problems
in psychosocial functioning. Children with SCD have dis-
played less body satisfaction (Morgan & Jackson, 1986), less
interaction with peers (Kumar, Powars, Allen, & Haywood,
1976), doubts about their ability to become independent