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Cognitive-behavioral interventions for children's distress during bone marrow aspirations and lumbar punctures: A critical review
Vol. 9 No. 2 Febnrav 1994
96 Journal of Pain and Symptom Management
Cognitive-Behavioral Interventions for Children’s Distress During Bone Aspirations and Lumbar A Critical Review Jacqueline A. Ellis, MSN, and Nicholas P. Spanos, PhD Schoolof Nursing U.A.E.), Universityof Ottawa;and Department of Psychology (N.P.S.), Carleton Univmi&
Ottawa, Ontario, Canada
Abetruet Children with cancer o@n have dijficulty coping with the invasive medical procedures that are part of diagnosis and treatment. Bone marrow aspirations and lumbar-punctures arepainful and cause some children severe anxiety and distress. The increased risk and ex@se of general anesthesia and the relative ineflectivenessof sedatives and anxiolytics has prompted clinicians to examine nonpharmacologic methodsfor controlling pain and distress. This n$ort critically examines intervention studies thatfocus on cognitive-behavioral strategies such as distraction, imagery, or hypnosisfor reducing procedural distress in children with cancer. J Pain Symptom Manage 1994;9:9&108.
Procedural distress, cognitive-behavioral interventions, psychological aaalgesia, pain
One of the most difficult aspects of children’s cancer treatment is coping with repeated bone marrow aspirations, lumbar punttures, venipunctures, and fingersticks. These diagnostic and monitoring procedures are an essential part of treatment but are painful and distressing. Some children develop anxietyrelated symptoms such as nausea, vomiting, anorexia, skin rashes, insomnia, nightmares, and depression in anticipation of painful procedures.’
--A
Address reptint requests to: Jacqueline
A. Ellis, RN, School of Nursing, University of Ottawa, 451 Smythe Road, Ottawa, Ontario KlH 8M5, Canada. Acceptedfor publication: August 4, 1993. U.S. Cancer Pain ReliefCommittee, 1994 Published by Elsevier, New York, New York
Bone marrow aspirations (BMAs) are perceived by children as the most painful and distressing procedures followed by lumbar punctures (LPs) and then venipunctures.**s Immediately prior to and during these procedures, children often show acute distress in the form of crying, screaming, hostility, uncooperative behavior, and aggression.‘,” Afterward, they may be withdrawn and angry, embarrassed by their disruptive behavior, but uncooperative. Distress does not consistently decrease over time,‘*s and in some cases it may increase with the number of procedures performed.4 This article reviews the empirical evidence regarding the efficacy of cognitive-behavioral methods for alleviating pain and distress associated primarily with BMAs and LPs. The first section addresses the use of pharmacologic
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for pain control and examines factors contribute to the ~~ab~li~ in children’s distress. In the second section, intervention studies that focus on cognitive-behaviora strategies are reviewed. The third section reviews studies that employ h~~osis and studies that compare h~notic inte~e~tio~s to cognitive behavioral techniques. In the final section, methodologicai issues, conclusions and directions for future research are discussed. methods that
A primary debate in clinical practice concerns the issue of what role pharmacologic treatment versus co~itive-shalom methods shouid play in the dearest of procedural distress. A subcommittee on procedural pain from the Consensus Conference on Management of Childhood Cancer Pain” recommends aggressive pha~aco~o~i~ mana~eme~&, i.e., conscious sedation or general anesthesia, for the initial BMA and LP. For children under 5 years of age, they recommend conscious sedation or gene& anesthesia for all subsequent procedures. For children older than 5 years, they suggest an indi~dualized approach using behavioral and pharmacologic interventions alone or in combination.” These recommendations followed the observation that painful procedures were not being managed effectively or consistendy at many hospitals and oncology centers6 A survey of 29 Pediatric Oncology Group (POG) institutions indicated that 20% never used drugs for BMAs and 34% never used drugs for LPs.’ Of the 68% and 59%, respectively, that sometimes used drugs, the most commonly used were a combination of intramuscufar meperidine, promethazine, and chlorpromazine (so-called DPT) or chloral hydrate given by mouth. The sedative effects of the promethazine and chlorpromazine make this combination of drugs unacceptable for a number of children. Some children report feeling *‘out of control” and so sieepy that they cannot cope with the procediire.2,n They may be combative during the procedure acd sleep for several hours afterward, which often interferes ~th their return to norma! activities. fn addition, profound respiratory depression was reported in four 695 patients given DPT.”
and ~e~~~~ anes used for pa~nf~~ procedures in are becoming more widely used in erica. SpWifiCLdly, intravenous mim alone, or in Combination with an analgesic such as fe~~ny~ has proven to be safe and effective for controlling pain and distress.‘U Midazolam produces effective sedation of short duration, anterograde amnesia, and anxiolysis, with relatively few adverse effects.1”J2 Children are very reiaxed but easily aroused, with intact airway reflexes. The major risk ~oc~ated with mid~o~am is ~~ove~~~ation and subsequent bypoxemia. Careful monitoring of the patient, access to supplemental oxygen, resuscitation equipment, and personnel skilled in pediatric airway management are essential. Protocols for administering conscious sedation usually specify that someone be designated (e.g., a rmrse) to monitor airway patency, viral signs, and oxygen saturation during the procedure and the recovery phase, which usually lasts about 6c) min. The decision to offer conscious sedation for procedural distress is, in part, contingent upon the availability of the appropriate equipment and personnel. The potential for complications is underscored in a case report of a I4monthold patient who experienced signi~cant respiratory depression and cyanosis follo~ng the administration of fentanyl and midazolam.‘” The lack of cardiorespiratory monitoring and pulse oximetry delayed intervention until the child became visibly cyanotic, further complicated by the lack of supplemen~l oxygen at the bedside. The point of the case report was not to highlight the dangers of conscious sedation rather to emphasize its safety, given the appropriate technical and professional support. Current research has been directed at dete~ining the safety and efficacy of conscious sedation protocols that could be implemented by oncologists or nurses. ‘2 Otherwise, the impracticality of having an anesthesiologist present for every procedure might preclude the use of conscious sedation by smaller hospitals and oncology centers. The minimal pharmacologic interven!ion fOr au LP or BMA is a local anesthetic at the site. prior to the approval of an anesthetic r earn (E&&A), this involved a needlestick, which many children find distressing. EhKA is a eutectic mixture of local anesthetics that ~~~scio~s
se~a~~~
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effectively alleviates needlestick pain. EMIA has been used with adults for dermatologic procedures and with children primarily for pain associated with venipunctures. In two controlled studies, EMIA was more effective than either a placebo, or no treatment for decreasing pain associated with lumbar puncture in 18 children.14
Factors Afecting Pain and Distress The terms behavioral anxiety, procedural distress, and distress are used to describe a complex interaction of cognitive, affective, and behavioral responses to a situation that involves pain. It is often impossible to separate pain from the anxiety and fear that children experience during a medical procedure. A host of factors contribute to the overall unpleasantness of the situation, including the unpredictability and the loss of control that are part of being restrained and forced to submit to a painful procedure. One of the benefits of conscious sedation is that children do not remember the procedure, are comfortable and relaxed, and thus do not get into a cycle of increasing anxiety with each procedure. A distinct disadvantage of sedatives such as chloral hydrate or promethazine and chlorpromazine is the accompanying drowsiness in combination with anxiety and fear, all of which tend to augment the feelings of losing control for some children. Children are not equally distressed by medical procedures. A substantial number declined participation in the intervention studies and expressed confidence in their own abilities to manage the pain and anxiety associated with procedures. Zeltzer and I_eBaron’” found that 12 (27%) of 45 children, and Jay and colleague@ found that 14 (16%) of 87 children asked to participate in an intervention study reported no need for additional help in coping with BMAs or LPs. Hilgard and IeBaront” offered 63 children the chance to learn hypnosis to control procedural distress, and 24 accepted the offer. The other 39 children (62%) felt they were coping well and did not need assistance. Factors that contributed to the variability of pain and distress behavior included the age and gender of the child,' St4 the level of parental anxiety, the parents’ anticipation of their child’s pains generalized fear of medical procedures, and coping style.17
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A number of investigators reported differences in the intensity and types of children’s distress behaviors as a function of age and children overall scored gender. Younger higher on measures of distress,‘+s:R*lsexhibited more types of distress behaviors (e.g., crying, screaming, refusal to hold the position, flailing, and clinging), over a greater time period, than did older children.’ Around age 7 years and older, children exhibited more behavioral control and tended to express their pain and fear verbally.” They were more able to articulate their fear and ask for support. Although younger children consistently exhibited more overt physical manifestations of distress, lack of behavioral control was not always correlated with self-reports of pain.s For some children, combative or active behaviors may be distracters that enable them to attend away from the procedure, which in turn may alter their perception of the intensity of the pain. Although their active behaviors are classifled as indicators of distress on many observational tools, their self-reported pain may be relatively low. In such cases, both self-reports of pain and behavioral assessments are essential to provide a complete picture of the children’s experience. Gender differences in behaviosal distress have not been as consistently reported as age differences. Katz and colleagues’ reported that girls scored higher than boys and were more likely to cry, cling, and request emotional support, whereas boys were more likely to engage in stalling behaviors. A number of other investigators, 5.8*18however, reported no difference in overall distress or types of distressrelated behaviors as a function of sex. Research to determine what effect children’s coping style has on pain perception and distress has provided mixed results. Typically, behaviors, attitudes, cognitions, etc., are dichotomized into opposing categories and used as a labeling variable. The lack of clear evidence for a definitive link between coping style and distress may be, in part, due to the difficulty of neatly summarizing the complexities of a multidimensional, interactive process that typifies coping. Hubert and colleagues’!) conceptualized coping style along the dimension of approach or avoidance based on the child’s request for information about the BMA. Children that
Ir,L 9 NQ. 2 FebnraT
1994
~ognilirle-~ellazlioral
actively sought information, participated in practice demonstrations, and listened to preparatoty information about the BMA or LP were considered to have an approach style of coping. Avoiders were uncooperative and uninterested in preparatory activities before procedures. They found no relationship between distress scores and informa~o~-seeking disposition in patients undergoing LPs and BM,As. Smith and colleaguessU used a similar approach-avoidance dichotomy and then matched the child’s coping style with an intervention they believed best suited to that style. The interventions consisted of distraction or information about the sensory aspects of the BhfA or LP. They found no difference in distress scores or self-reported pain between the two groups, and no support for the idea that a “goodness of fit” between coping style and the interventions would produce greater pain and distress reductions. Broome and colleaguesi found that children who displayed active or actionoriented coping behaviors (i.e., asked questions, attempted to control, and resisted) reported less pain during lumbar puncture than children who used passive coping behaviors (i.e., ignored staff, remained silent and motionless, and cooperated without complaint). F_elatedly, Hester*’ found that children who fought and cried during immunization reported less pain than children who passively complied. An appropriate intervention for this group of children might be to keep *hem informed of the progress of the procedure so they can scream at the appropriate moment. In this way, encouragement and praise for “good screaming” may validate the child’s efforts to take control of the situation.
Jay and colleagues s~s~*-s4conducted a series of studies that systematically examined distress behavior, antecedent variables and the effects of behavioral and pha~acoiogic inte~entions on procedural distress. In their first study, they designed and piloted a cognitive-behavioral therapy (CBT) package that was based on a stress-inoculation model.“2 Stress inoculation refers to a set of procedures that provides the
Interventions
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individual with imaginative and cognitive strategies for pain reduction. Motivational instructions, i~fo~atio~, and Opportunities to pmctice the s~tegies form a multidimens~o~a~ package designed to help the in&vi&la] cope. PBThe CBT package consisted of attention diversion, reinforcement, imagery, behavioral rehearsal, and filmed modeling. Five children aged 3-7 years, referred for severe anxiety and behavioral distress related to BMAs and LPs, reduced their distress scores after iute~entio~ by at least 50%, The next study was a ~ompa~so~ of the CBT package with oral diazepam and an attentionCOINI-01condition (30 min of cartoon watching prior to the BMA) delivered in the context of a repeated-me~ures, counterbalance design.” A total of 56 children with leukemia, aged 3-13 years, were assigned one of six possible sequences with the stipulation that subjects given each sequence were equally proportioned according to age, gender, and previous experience with BMAs. Dependent variables were scores on the Observational Scale of Behavioral Distress (OSBD), self-reported pain, pulse, and blood pressure readings. Overall, children had significantly lower pain ratings, OSBD scores, and pulse rates when in the behavior-therapy condition as compared with either the diazepam or the attention~~ntrol group. Diazepam was useful for lowering anticipatory distress but had no effect on distress during the procedure (encounter phase). In fact, there was no difference between treatments in OSBD scores when the encounter phase of the BMA was analyzed separately. Considered to be the most painful, this phase includes cleansing of the puncture site, instillation of local anesthetic, and aspiration of the bone marrow. The lack of difference between treatments in the encounter phase of the BMA serves to highlight the complexity involved in evaluating the clinical relevance of a ~ha~o~l intervention. Collapsing across phases and comparing the total scores may lead to an overestimation of the usefulness or misapplication of the behavioral strategy. An intervention that appears to be effective overall may actually be most effective when used to manage distress in the anticipatory and recovery phases of the procedure. A different type of intervention may be needed to manage the more intense sensory experience of
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phase of the BMA. However, an improvement during the anticipatory and recovery phase may still be a meaningful improvement to the experience overall. It is interesting that no main or interaction effects were found for the sequence of the intervention. This implies that coping sttategies learned in the behavior-treatment condition were not used in subsequent BMAs where children were not specifically told how to cope. Similar findings were obtained in other studies. Dalquist and colleagues2s and Blount and colleagues27 reported that a majority of children undergoing a BMA or LP did not engage in coping strategies unless prompted to do so by an adult. In a laboratory setting, Spanos and colleaguesss demonstrated that subjects often refrained from using coping strategies unless explicitly told to do so. Subjects given the simple instructions “do whatever you can to reduce pain” showed greater pain reduction than controls given no instructions and equivalent pain reduction to a group given a coping suggestion. A limitation of both of the studies by Jay and of the colleagues’s~2z was the confounding behavioral treatments with support and coaching from the parent and/or psychologist. What constitutes professional or parental support and coaching should be made explicit. As reporied, this was an uncontrolled variable and may not have been consistent among all subjects, yet support and coaching may be salient factors in the effectiveness of the intervention for reducing distress. This needs to be examined more closely and systematically varied to determine what portion of the variance in distress scores is due to the intervention (i.e., distraction, imagery, etc.) and what is due to parental or therapist coaching and support. Perhaps it is the interaction of coaching and coping strategies that is most effective for reducing distress. The effectiveness of the oral diazepam for reducing anticipatory anxiety and the CBT package for reducing distress prompted Jay and colleagueG4 to examine the combined effects of oral diazepam and CBT, Within a repeated-measures factorial design, 83 children aged 3’/~12 years were assigned to either a CBT or CBT-plusdiazepam condition. Both groups reduced their OSBD and self-reported pain scores after the intervention; however, the
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CBT-plus-diazepam group had only one-third the reduction as compared with the children in the CBT-alone group. The investigators suggested that the diazepam may have interfered with the learning of the cognitive-behavioral strategies. In addition, the children may have been unable to remain focused on the imagery and distraction tasks during the procedure due to the effects of the diazepam. Parents of the children in the CBT plus diazepam study were offered an intervention to decrease their own stress resulting from their child’s painful medical procedures.“” Data from previous parent interviews” indicated that parental anxiety was positively correlated with the children’s procedural distress. A stressinoculation intervention specific to the needs of the parents was offered to one group of parents, with the second group simply observing their children undergoing the CBT program. The stress-inoculation group demonstrated larger decreases in state and trait anxiety from baseline than did the observation group. The decrease in anxiety for the parents, however, had no effect on the children’s behavioral distress or self-reported pain.
Procedures labeled as “hypnotic” have been employed for over a century to reduce pain associated with a variety of medical conditions. Hypnosis has been used for pain control with children experiencing headaches, burns, chronic recurrent abdominal pain, and sicklecell crisis. Most of the evidence for the effectiveness of hypnotic procedures is anecdotal or based on case reports. The few controlled studies have been done with children undergoing BMAs or LPs. Theoretical controversies concerning hypnosis center around the assumption that hypnosis is associated with a particular psychological or physiologic state that can be readily recognized and reliably produced with an induction ritual. Typically, a hypnotic induction contains suggestions for relaxation, sleepiness, eye closure, and suggestions for entering hypnosis. Substantial research has failed to identify physiologic, behavioral, and verbal report indicators that unambiguously reflect an hypnotic siate (as opposed to relaxation, expectancy-induced behaviors, etc.).E1-st
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Cognitive-Behavioral Intenmtiow
Traditional interpretations of hypnotic analgesia view the induction procedure and the assumed hypnotic state as critical for pain reducti0n.s~ According to ~iI~rd,~~~ b~~~t~c analgesia is the result of an amnesialike process that involves the dissociation of pain from phenomenal awareness. Consistent with this hypothesis, only highly h~~otizable subjects {i.e., those that score high on scales that assess responsiveness to a standardized series of hypnotic suggestions) possess the ability to dissociate and thus experience high levels of h~nodca~y induced pain reductio~.~~ An alternative perspective conceptualizes hypnotic responding as continuous with other types of complex social behavior. According to this view h~notic responding can be accounted for by using constructs regularly employed by social and cognitive psychologists to explain other forms of social behavior (e.g., attitudes, expectaGons, interpretations, role enactment, and self-e&a+. ~~notic sub jects are viewed as performing goaldirected actions based on an understanding of the demands of the situation. From this perspective, hypnotic analgesia does not occur automatically and i~vQiun~~ly. Rather, it is the result of the individual actively engaging in cognitive activities to ameliorate the effects of the noxious stimulation. According to this perspective, subjects low in b~notizabili~ can be induced in various ways to reduce pain to the same extent as highly hypnotizable subjects (for a more complete discussion, see Spanos and ChaveG4f _ A number of intervention studies examined the effectiveness of hypnotic interventions, or compared such interventions t.o other cognitive-behavioral strategies for relieving procedural pain and distress. It is difficult to compare studies that employ hypnotic i;lterventions because there are no standardized procedures in the clinical use of hypnosis that define a situation as hypnotic. In the laboratory pain literature, the term hypnotic analgesia condition refers to a standardized induction followed by a set of standardized imageq-based analgesia suggestions. Nonhypnotic condition refers to the same analgesia suggestions without the initial hypnotic induction. In the clinical studies reviewed, there were a variety of di@erent procedures labeled hypnotic that included some combination of an’ induction,
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breathing exercises, istraction, imagery, suggest.ion, and therapist support. There was no s~~dardizado~ across the studies, however, and in several studies t e procedures were never defined as hypnotic to either the patients or their parents. Milgard and LeBaronui were among the first i~ves~~to~ ~stemadc~ly to study the use of hypnotic procedures for alleviating procedural distress. A total of 24 children (aged 6-19 years) participated in a hypnotic intervention that consisted of eye fiation and closure, followed by suggestions for relaxation, imagery, and the suggestion for comfort during the BMA. The therapist directed the children through a rehearsal of the BMA and acted as a coach during the actual procedure. Overall, there was a statistically significant reduction in self-reported pain, and observer-reported pain and anxiety, after the hypnotic treatment. Subjective pain ratings decreased from a mean of 7 prehypnosis to a mean of 5 after hypnosis. Keller-man and colleagues4 studied the effect of an hypnotic intervention that consisted of an induction technique, rhythmic breathing, suggestions for progressive muscular relaxation, increased well-being, and visualization of a favorite or special place. A total of 16 adolescents, preselected for high levels of procedural distress, were taught self-hypnosis and given the opportunity to practice it prior to a procedure. During the BMA or LP, “additional suggestions for enhanced comfort were g-*hen” (p. 87). Neither the role of the hypnotherapist during the procedure nor how much of the intetvention was self-hypnosis as opposed to therapist directed is clear. Consequently, it is difftcult to interpret the effect of attention or support on pain and distress. All 16 adolescents showed a significant reduction in self-reported pain and anxiety from baseline to posttreatment. As the authors point out, the data do not establish which aspect of the treatment was most effective for reducing distress. The lack of a control group makes it difftcult to attribute the change unequivocally to the treatment. The attention and support from the therapist prior to, and possibly during, the procedure may have been a factor contributing to the reduction in distress. Katz and coileaguess” compared hypnosis with an attentioncontrol treatment (unstructured play sessions prior to the BMA) with 36
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subjects, 6-12 years of age. The hypnotic intervention included an induction, muscle relaxation, imagery and suggestions related to coping with the sensory-pain aspects of the Suggestions for practicing and experience. reentering hypnosis when cued by the therapist were included during a series of training sessions. Roth groups showed equivalent reductions in self-reported pain and fear from baseline measures, but the pain scores consistently increased from first to third BMA. Distress scores between groups were not signilicandy different, with children in both groups exhibiting increasing distress from baseline to the third BMA. The children were expected to transfer information learned during the hypnotic training sessions to the bone marrow procedure independent of coaching from the therapist. This may have been too much to expect from the children given the magnitude of the anxiety and distress typically associated with these procedures. In fact, the presence of the therapist without attempts to aid in coping may have been frustrating for some of the children and may have actually increased their distress. Related clinical research with childrensse**7 and laboratory research with adultszs has shown that individuals are more likely to use coping strategies if prompted to do so.
Cognitive Strategiesversas ~y~~~ Three studies have compared cognitive strategies with hypnotic interventions to determine the method most effective for reducing procedural distress. Zeltzer and LeBaron’s compared a combination of deep-breathing exercises and nonima~nal distraction activities (e.g.. hand squeezing, talking, and counting) with treatment that included therapist-assisted deep breathing and pleasant imagety that the investigators labeled as hypnotic. The imagery-based strategy was not defined as hypnosis to either the children or families, however, and did not include a h~notic-induction procedure. Tbus, it is more accurately described as a guided imagery treatment than a hypnotic treatment. Both interventions were effective at reducing the pain ‘N4.s and the anxiety associated with LPs. rniitnough Zehzer and I..eBaron’s argued that hypnosis was more effective than a nonhypnotic treatment for reducing pain and anxiety, it is
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more accurate to conclude that, in their study, guided imagery was more effective than distraction for reducing pain and anxiety. Wall and Womack”” compared a hypnotic treatment that consisted of an induction procedure, relaxation, and visual imagery with a nonhypnotic distraction procedure. The ages of the 20 children in the study varied from 5 to 18 years. Both inte~entio~s were equally effective for reducing self-reported pain, but neither intervention had an effect on anxiety. Kuttner and colleaguess7 compared distraction, a procedure labeled hypnosis/imaginative involvement, and a standard practice control group, in the reduction of procedural pain and distress during BMA in 30 children, 3-10 years of age. In the distraction intervention, a therapist engaged the children in blowing bubbles, counting, puppet play, and looking at pop-up books during the procedure. The hypnotic group received a combination of hypnotic suggestion, guided imagery, and therapist support. Following treatment, each child was assessed during two B&Us. The only significant finding to emerge indicated that, among younger children (3 years to 6 years 11 months), the hypnotic treatment produced lower distress scores than did the distraction or control treatments in the first BMA only. By the second BMA, the younger children in the three groups showed equivalent reductions in distress scores. There was no significant differences in self- reported pain and anxiety among the three groups. In the hypnosis studies reviewed, it is difIicult to interpret the reductions in pain and distress as attributable specifically to the hypnosis and not some other aspect of the intervention. For example, in the study by Kuttner and colleagues,“’ the hypnosis group used imagery, suggestion, and therapist support while the control group used bubble blowing, counting, puppet play and pop-up books. To compare precisely the effects of hypnotic procedures on distress it would have been more useful to have both groups engage in the same activities, e.g., bubble blowing, pop-up books, guided imagery, etc., with these activities preceded in one group by the hypnotic induction. Any differences between the groups could then have been unambiguously attributed to the one variable that differed between them, the hypnotic-induction ritual.
In adult ~a~o~t~~ and clinical studies that separated the induction from the suggestions, imagery, distraction, etc., results consistency indicate that psycbolo~c~ treatment in the absence of hypnotic induction are always at least as effective as the same psychol~~c~ ~e~~~n~ preceded by hypnotic induction.gK-41 Three studies1G-35”6 examined the relationship between h~~oti~bi~i~ and pain relief during BMA. Hilgard and I_eBaron’C’ reported a sig~~~nt relations~p between these variables, whereas Katz and colleaguesS5 and WaII and Womack~6 found no rela~ons~ip between the variables. Similar inconsistencies bave been found in the adult clinical literature concerning the relationship between h~notizabiIi~~ and pain reduction. Taken together, these findings suggest that the relationship between hypnotizability and pain reduction is mediated by other variables (see Spanos and colleaguesJz for a review) _ Consistent with these adult clinical and laboratory studies, the pediatric clinical studies seem to indicate that hypnotic procedures provide no added benefits to those achievable with distraction, imagery, etc. Due to the imprecision with which the consltruct ofhypnosis was operationalized and lack of standardization across studies, however, it is impossible to draw definitive conclusions. While it is tempting to conclude there appears to be no clear benefits to hypnosis, the term should be clearly defined and unambiguously implemented in pediatric clinical studies before this can be concluded.
Taken together, the results of these studies (see Table 1) support the findings of numerous laboratory pain studies that indi~du~s can gain at least partial control over discomfort by controlling and directing their cognitive activities. A variety of interventions such as unstructured play, cartoon watching, relaxation, distraction, imagery, and hypnosis comprised interventions that helped children to cope with pain and anxiety. Most interventions were presented as muiticompone~t packages and were evaluated in terms of their overall effect on pain and distress. Questions remain as to which aspects of the interventions are useful ove;rail, or more appropriate for a specific
at the specific components of these ages and what effect the i~te~e~tio~ has OIJ the different phases of the aversive procedures. ~~teresting and relevant i~f~rrna~o~ has atso been uncovereJ during the process of ~de~d~ng ir~di~duals who are highly distressed by procedures. In searching for “volunteers,” investigators have found a group of chiIdreR that refused the offer to ~ar~cipate because they felt they were coping well on tbei~ CBW. St~d~~g this group of natural ‘“capers” might help in determining the variables that mediate successful coping. What a~~t~des, motivations, ex~ec~~o~s, and cognitive skills do these children have that enable them to manage successfully adopt as&stance? A growing body of literature on adult pain suggests that distraction and imagery work, in part, by encouraging coping cognitions and diminishing catastrophizing.4g*44 Ca~~opbizing refers to the tendency of individuals to focus on and exaggerate the negative aspects of the noxious situation, and the tendency to feel ove~heImed and unable to cope or control the situation.44+45 The natural capers appear to be at one end of a continuum that is balanced at the other end by children who reported high Levelsof pain and distress even after i~te~ent~o~s. For exampleJay and coIleaguesz4reported that, on a bpoint scale, 34% of 83 subjects rated their pain as a 4 or 5 and 24% rated their fear as a 4 or 5 postintervention. Do these children f?t the profile of the catastrophizer as described in the adult pain literature? What variables or cognitive activities differentiate these children from those who cope well on their own and those who successfullyuse the psychological interventions to reduce pain and distress. It is clear that not all children do equally well using psychological analgesia, but the reasons for this have yet to be empirically described. It may be that some children, similar to some adults, are able to genera&e imagery and distraction coping strategies spontaneously to reduce their distress. Other children may continue to catastrop&e even when prompted to use imagery or distraction. There is some evidence that the lack of ca~~o~hizing cognitions determines pain reduction more so than the presence of coping cognitions.4f’
Baseline-posttest
Repeated measures counterbalanced
hei 3-7 yr
M56 3-13 yr
AW3 3.5-12 yr
&72 Parent of children in previous study (79% mothers)
i-24 6-19 yr
W16 11-yr
Jay and colleagues**
Jay and colleague@
Jay and colleaguesV4
Jay and Elliot”
Hillgard and LeBaronlG
Kellerman and colleagues4
Baseline-posttest
Baseline-posttest
Repeated-measures factorial
Repeated-measures factorial
Design
Patients
Investigators of intervention
CBT package CBT package plus oral valium
Intervention: hypnosis = (induction) eye fixation or hand levitation, rhythmic breathing, suggestions for relaxation, increased well-being, visualization of a favorite place, posthypnotic suggestion for comfort and mastery during the procedure
Intervention: hypnosis = (induction) eye fixation and closure, suggestion for relaxation, imagery, posthypnotic suggestion for comfort during BMA
Intervention: stress-inoculation procedure = film about cancer and helping children cope with procedures, relaxation training, and positive self-statement training. Control group: parents accompanied their children during CBT training
Intervention: Intervention:
Intervention: CBT packaged as described above. Intervention: oral valium Control: 30 min of cartoon watching
Intervention: cognitive behavior therapy (CBT)= breathing exercises, trophy as reinforcement, imagery, behavioral rehearsal, and film of child successfully coping with bone marrow aspiration (Bm)
Description
Table 1 Comparison of Intervention Studies variable
Self-reported pain and selfreported anxiety
Self-reported pain and observerrated anxiety
Parent behavior scale, state-trait anxiety inventory, selfstatement inventory for medical procedures, selfreported coping diffhzulty, pulse, and blood pressure
OSBD scores, and self-reported pain
OSBD scores, self-reported pain, pulse, and blood pressure
Observational scale of behavioral distress (OSBD)
Dependent
Significant reduction in pain and anxiety from baseline to posttreatment
Significant reduction in observer-rated anxiety and self-reported pain from baseline to posttreatment
Stfesdnoculation group showed greatest decrease in state-trait anxiety from baseline to time 2 No other significant difference
Both groups reduce OSBD and pain scores, CBT plus valium, less reduction then CBT alone
Lower OSBD scores, pulse rates, pain scores when in CBT intervention as compared with cartoon watching or oral Valium all three groups had equivalent OSBD scores during encounter phase of BMA
50% reduction in OSBD scores after intervention
Results
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8.
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8,
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Intervention: hypnosis = (induction) arm levitation, relaxation, visual imagery, cued to use hypnosis with taped tnessage Intervention: some type of disuacdon strategies to shift attention away frottt the procedure
Repeated-measures factorial
IV=20 5-18 yt
Wall and Womack!t”
,,,,,
No significant difference in distress scores for older children, younger children itt hypnosis/imagery groups had lower distress scores on first BMA only, tto significant difference in pain and anxiety among groups
PBRSr, obsenver-rated anxiety, observer-rated pain, selfreported pain, and selfreported anxiety
Intervention: distraction (bubble blowing, pop-up books, puppet play, deep breathing) Intervention: imaginative involvement/ hypnosis = suggestions for time reduction, analgesia using a pain-switch technique, and itnaginative stories Control condition: information about the procedure, reassurance during the procedure
Repeated-measures factorial design
IV=30 3-10 yr
Kuttner and colleagued7
,m”.
>.,,
,,<,,,
,,
,,
.
Both interventions effective for reducing pain but not anxiety No difference in paitt or anxiety reduction lhetweett groups
BMA pain significantly reduced in both treattttcnt groups, anxiety reduced in hypnosis/itnagcty group only Lutnbar puncture (LP): pain significantly reduced in hypnosis/itnagety group only, anxiety significantly reduced in both treatment grottps. Overall hypnosis,‘itnagety associared with grenter reduction in pain and anxiety than distraction
Self-reported pain and selfreported anxiety
Intervention: hypnosis = described as therapist-assisted itnagety Nonhypnotic condition: deep breathing, distraction (counting, hand squeezing, and talking)
Repeated-measures factorial design
hF_33 6-17 yr
Zeltzer and LeBaront”
Self-reported anxiety, selfreported pain, observer-rated pain, and observer-rated anxiety
No significant diflerence in distress between grottps, distress scores increased frotn lirst 10 third BMA, equivalent reductions in self-reported pain and fear from baseline to posttreatment in both groups, consistent increase in scores from first to second BMA
Procedural Behavior Rating Scale-Revised (PBRSr), nurse rating of anxiety, self-reported fear, self-reported pain, therapist-patient rapport ratings, and response to hypnosis ratings
Results
httervetttion: hypnosis = (induction) eye fixation with or without eye closure, imagery, tnttscle relaxation, and suggestion related to coping with sensoty aspects of Bh4A Posthypnotic suggestion for reentering hypnosi.; with cue frotn therapist Control: unstructured play sessions prior IO BMA
variable
Repeated-tneasrtres factorial design
Dependent
AF-36 6-12 yr
of intervention
Katz and colleagues!‘s
Description
Patients
Investigators -
Design
Table 1 (continued) Comparison of Intervention Studies
106
Ellis and Spanos
The studies reviewed focused predominantly on outcome, i.e., the reduction of pain and distress. Future research might profitably be directed at determining the individual or situation variables that mediate reductions in pain and distress. For example, patient-therapist relationship variables may be important in influencing children’s response to psychological interventions. Katz and colleagues’ reported a negative correlation between selfreported pain and therapist-child rapport during training sessions and a posttreatment increase in distress that could have been influenced by the minimal therapist support during the encounter phase of the BMA. Motivation and self-presentation are variables that may facilitate the process of learning and applying coping strategies. For example, motivation to present oneself as strong, competent, and able to manage may be an important factor in determining a child’s willingness to learn coping strategies and master the painful situation. The children who have both the motivation and the facility to use imagery and distraction may need only reinforcement for work well done. Other children may initially need a combination of motivational information and uraining, but can then use the strategies on their own, while another group ~rl?y need support to maintain motivation and strategy ‘use. If certain children are unmotivated to master the situation and uninterested in learning coping strategies, then this group might be appropriate candidates for the use of conscious sedatic .I during every procedure. The choice of whether to use cognitivebehavioral strategies or ronscious sedation is an issue that deserves some attention. The ideal situation would be to have both treatment modalities available, so that choices could be made based on the age and preference of the child and family. Some centers are not equipped to offer conscious sedation, however, and some children feel the benefits are outweighed by the inconvenience. Conscious sedation adds a considerable amount of time and technology to what are otherwise two relatively simple procedures. When such sedation is employed, children typically are allowed nothing by mouth for at least 4 hr before the procedure. During the procedure, they are monitored with a cardiorespiratory monitor and an oxygen saturation monitor, numerous
Vol. 9 No. 2 February 1994
sets of vital signs must be monitored, and the patients must wake up fully before they are allowed to leave the clinic. For some children and families, this added inconvenience outweighs the benefits of decreased pain and distress. The fact that children around age 7 years are better able to articulate their fears and communicate their need for support and control’ could be used as an age guideline for introducing the idea of choice to the child. Younger children might be given conscious sedation for all procedures and older children might opt to try distraction or imagety, initially for LPs (the less painful of the two procedures) and then, if successful, during BMAs. The particular strategy, i.e. blowing bubbles, counting, imagining, screaming etc., is probably not as important as children understanding what works best for them, and what amount and type of support they need from the people around them. “What can I do to help you make it through?” is a question that needs to be carefully considered and could form the basis of a written action plan to be used during procedures. The plan could be updated and augmented as children discover the right mix of activities and support that enable them to cope. Careful consideration of the child’s perspective on his or her own ability to cope is essential. Because self-report remains the best way to assess the affective and sensory component of pain, it is not appropriate for physicians, nurses, or families to decide the child is “doing ok” without input from the child. Oncology nurses are in an excellent position to develop, implement, and evaluate the plan for coping with painful procedures. Increasingly, nurses are designated as “case managers” or “primaty nurses,” and, as such, deliver and coordinate care for a specified caseload of children. In this capacity, nurses develop rapport and trust with children and their families. Because a nurse is always at the bedside assisting during procedures, it seems a logical and costeffective use of existing resources to offer nurses the opportunity to become proficient in the use of psychological analgesia. A number of resources including books,47*4* articles,4!) video_ tapes?O and workshops are available to facilitate nurses’ understanding of these techniques. The best possible outcome for children who must undergo painful procedures will probably be
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Cognitive-Behavioral Inhvmtions
achieved with some mixture of pharmacologic and behavioral support. Reliance on either alone will probably not meet the needs of all children.
@S
1. Katz ER, Kellerman J. Siegel SE. Beha~o~9 distress in children with cancer undergoing medical procedures: developmental considerations. J Consult Clin Psycho9 1980;48:356-365. 2. McGrath PJ, HSU E, Cappelli M, Luke B, Goodman JT, Dunn-Geier J. Pain from pediatric cancer: a survey of an outpatient oncology clinic. J Fsychosoc Oncol 1990;8:109-124. 3. Jay SM. Ozolins M, Elliott CH, Caldwell S. Assessment of children’s distress during painful medical procedures. Health Psycho1 1983;2:133-147. 4. Kellerman J, Zeltzer L, Ellenberg L, Dash J. Adolescents with cancer: hypnosis for the reduction of the acute pain and anxiety associated with medical procedures. J Adolesc Health Care 1983;4:85-90. 5. Schecter NL, Altman A, Weisman S. Report of the consensus conference on the management of pain in childhood cancer. Pediatrics 1990;86(suppl): 813-834. 6. Zeltzer LR, A&man A, Cohen D, LeBaron S, Munuksela EL, Schecter NL. Report of the subcommittee on the management of pain associated with procedures in children with cancer. Pediatncs 1990;86:826-831. 7. Hockenberry MJ, Bologna-Vaughn. Preparation for intrusive procedures using uoninvasive techniques in children with cancer: state of the art vs. new trends. Cancer Nurs 1985;8:97-102. 8. Jay SM, Elliott C, Katz E. Siegel SE. Cognitivebehavioral and pharmacolo~c interventions for children’s distress during painful medicai procedures. J Consult Clin Psycho1 1987;55:869-865. 9. Nahata MC, Clotz MA, Rrogg EA. Adverse effects of meperidine, promethazine, and chlorpromazine for sedation in pediatric patients. Clin Pediatr 198~2~55~560. 10. Holmes CM, Galletly DC. Midazolam/fentanyl: a total intravenous technique for short procedures. Anesthesia ?982,37:761-765. 11. Diament I%$& Stanley P. The use of midazolam for sedation of infants and children. Am J Radiol 1985;150:377-380. 12. Sievers TD, YeeJD, Foley ME, Blanding PJ, Berde CB, Midazolam for conscious sedation during pediatric oncology procedures: safety and recovery parameters. Pediatrics 1991;88:1172-1179. 13. Yaster M, Nichols DG, Deshphande JR, Wetzel RC. Midazolam-fentanyl intravenous sedation in children: case report of respiratory arrest. Pediatrics 19~,8~~~7*
IOP
14. Kapelushnik J, Rome G, Solh H, Greenberg M, DeVeber L. Evaluating the efficacy of EMLA in alleviating pain associated with lumbar puncture: com~a~son of open and double-blinded protocols in children. Pam ~~~4~3~-~4. 95. Zeltzer L, LeBaron S. Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during
painful procedures in chi’ldren and adolescents with cancer. J Pediatr 198~,16~:1032-1035. 16. IiilgardJR, LeBaron S. Relief of anxiety and pain in children and adolescents with cancer: quanutauve measures and clinical observations. Int J @iin ~xp Hypn 1982;30:417-442. 17. Broome ME, Bates TX, Lillis PP. McGahee Tw; Children’s medical fears, coping behaviors, and pain perceptions during a lumbar puncture. Oncol Nu,r Forum 1990;173361-367. 18. Jacobsen PB, Manne SL, Gorfinirie R, Schorr 0, Rapkin B, Redd WH. Analysis of child and parent behavior during painful medical procedures. Health Psycho1 1990;9:559-576. 19. Hubert
NC, Jay SM, Saltoun
M, Hayes M.
Approach-avoidance and distress in children undergoing preparation for painful medical procedures. J Clin Child Psycho1 1988;14;194-202. 20. Smith KE, Ackerson JD, Blotcky AD. Reducing distress during invasive medical procedures: re9ating behavioral inteNentions to preferred coping style in pediatric cancer patients. J Fediatr Psycho1 1989;14: 465-419. 21. Hester NR. The preoperational child’s reaction to immunization. Nun Res 1979;28:250-255. 22. Jay SM, Elliott CH, Ozolins M, Olson RA, Pruitt SD. Behavioral management of children’s distress during painful medical procedures. Behav Res Ther 1985;23:513-520. 23. Jay SM. Elliott CH. A stress inoculation program for parents whose children are undergoing painfuf procedures. J Consult Clin Psychoi 1987;58:7!%804. 24. Jay SM, Elliott CH, Woody PD. An investigation of cognitive-behavior therapy combined with oral diazepam for children undergoing painful medical procedures. Health Psycho1 1991;10:317-322. 25. Turk DC, Meichenbaum D, Genest M. Pain and behavioral medicine: a cognitive behavioral perspective. New York: Guilford, 1983. 26. Dahlquist LJ, Gil KM, Armstrong D, De Lawyer DD, Greene P, Wuori D. Preparing children for medical examinations: the importance of previous medical experience. Health Psycho1 1986;5:249-259. 27. Blount RL, Corbin SM, Sturges JW, Wolfe W, Prater JM, James LD. The relationship &tween adults’ behavior and child coping and distress during Bm/LP procedures: a sequential analysis. Behav Ther 9989;20:585-601. 28. Spanos NP. Hodgins DC, Stam HJ, G-n M. Suffefing for science: the effects of implicit social
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1994
demands on response to experimentally induced pain. J Pers Sot Psycho1 1984;46:1162-1172.
pore-mandibular pain and dysfunction Psychosom Med 1984;46:534-545.
29. Barber TX, Spanos NP, Chaves JF. Hypnosis, ima~nation and human ~tential~ties. New York Pergamon, 1974.
40. Spanos NP, Stam HJ, Brazil K The effects of suggestion and distraction on coping ideation and reported pain. J Ment Imagery 1981;5:7!%-90.
30. Edmonston WE Jr. Hypnosis and relaxation: modern verification of an old equation. New York: John Wiley and Sons, 1980.
41. Spanos NP, Ollerhead VG, Gwynn MI. The effects of three instructional treatments on pain magnitude and pain tolerance. Imagin Cogn Pers 1986;5:321-337.
31. Periini AH, Spanos NP. EEG meth~olo~es and h~noti~bili~: a critical review. Ps~hoph~iol~~ 1991;29:51 I-530. 32. Hilgard ER. The problem of divided consciousness: a neodissociation interpretation. Ann NY Acad Sci 1977;296:48-59. 33. Hilgard ER. Divided consciousness in hypnosis: the implications of the hidden observer. In: Fromm E, Shor RE, eds. Hypnosis: recent developments and new perspectives. Chicago: Aldine, 1979:45-79. 34. Spanos NP, Chaves JF, eds. Hypnosis the cognitive-behavioral perspective. New York: Prometheus, 198~2~2~. 35. Katz ER, Kellerman J, Ellenberg L. Hypnosis in the reduction of acute pain and distress in children with cancer. J Pediatr Psycho1 1987;12:379-395. 36. Wall VJ, Womack W. Hypnotic versus active cognitive strategies for alleviation of procedural distress in pediatric oncology patients. Am J Clin Hypn 1989;31:181-191. 37. Kuttner L, Bowman M, Teasdale M. Psychological treatment of distress, pain, and anxiety for young children with cancer. J Dev Behav Pediatr 1988;9: 374-382. 38. Edelson J, Fitzpatrick JL. A comparison cognitive-behavioral and hypnotic treatments chronic pain. J Clin Psycho1 19;45:316-323.
of on
33. Stam HJ, McGrath PA, Brooke RI. The effects of a cognitive-behavioral treatment program on tem-
42. Spanos NP, Carmanico S, analgesia: laboratory and clinical P, Melzack R., eds. Textbook Edinburgh: Churchill Livingston,
syndrome.
Ellis JA. findings. of Pain, 1994 (in
Hypnotic In: Wall 3rd ed. press).
43. Spanos NP, Perlini AH, Robertson LA. Hypnosis, suggestion, and placebo in the reduction of experimental pain. J Abnorm Psycho1 198~9~28~~3. 44. Spanos NP, Brown JM, Jones 8, Homer D. Cognitive activity and suggestions for analgesia in the reduction of reported pain. J Abnorm Psycho1 1981;90:554-561. 45. Sullivan MJL. Bishop SR. ~~trophizing and pain. I. Scale development and validation (unpub lished manuscript). Halifax: Dalhousie University, 1991. 46. Sullivan MJ, Rouse D, Bishop SR, Cutler, M. Catastrophizing and pain. II. Thought intrusions and affective correlates (unpublished manuscript). Halifax: Dalhousie University, 1991. 47. McGrath PA. Pain in children: nature assessment and treatment. New York: Guilford, 1990. 48. Zahourek RP. Relaxation and imagery: tools for therapeutic communication and intervention. Toronto: WE Saunders, 1990. 49. Heiney procedures.
SP. Helping children through Am J Nurs 1991;91:20-24.
painful
50. Kuttner L. No fears no tears: children with cancer coping with pain (video). Vancouver: Canadian Cancer Society, 1986.
96 Journal of Pain and Symptom Management
Cognitive-Behavioral Interventions for Children’s Distress During Bone Aspirations and Lumbar A Critical Review Jacqueline A. Ellis, MSN, and Nicholas P. Spanos, PhD Schoolof Nursing U.A.E.), Universityof Ottawa;and Department of Psychology (N.P.S.), Carleton Univmi&
Ottawa, Ontario, Canada
Abetruet Children with cancer o@n have dijficulty coping with the invasive medical procedures that are part of diagnosis and treatment. Bone marrow aspirations and lumbar-punctures arepainful and cause some children severe anxiety and distress. The increased risk and ex@se of general anesthesia and the relative ineflectivenessof sedatives and anxiolytics has prompted clinicians to examine nonpharmacologic methodsfor controlling pain and distress. This n$ort critically examines intervention studies thatfocus on cognitive-behavioral strategies such as distraction, imagery, or hypnosisfor reducing procedural distress in children with cancer. J Pain Symptom Manage 1994;9:9&108.
Procedural distress, cognitive-behavioral interventions, psychological aaalgesia, pain
One of the most difficult aspects of children’s cancer treatment is coping with repeated bone marrow aspirations, lumbar punttures, venipunctures, and fingersticks. These diagnostic and monitoring procedures are an essential part of treatment but are painful and distressing. Some children develop anxietyrelated symptoms such as nausea, vomiting, anorexia, skin rashes, insomnia, nightmares, and depression in anticipation of painful procedures.’
--A
Address reptint requests to: Jacqueline
A. Ellis, RN, School of Nursing, University of Ottawa, 451 Smythe Road, Ottawa, Ontario KlH 8M5, Canada. Acceptedfor publication: August 4, 1993. U.S. Cancer Pain ReliefCommittee, 1994 Published by Elsevier, New York, New York
Bone marrow aspirations (BMAs) are perceived by children as the most painful and distressing procedures followed by lumbar punctures (LPs) and then venipunctures.**s Immediately prior to and during these procedures, children often show acute distress in the form of crying, screaming, hostility, uncooperative behavior, and aggression.‘,” Afterward, they may be withdrawn and angry, embarrassed by their disruptive behavior, but uncooperative. Distress does not consistently decrease over time,‘*s and in some cases it may increase with the number of procedures performed.4 This article reviews the empirical evidence regarding the efficacy of cognitive-behavioral methods for alleviating pain and distress associated primarily with BMAs and LPs. The first section addresses the use of pharmacologic
0
OS%-3924/94/$7.00
for pain control and examines factors contribute to the ~~ab~li~ in children’s distress. In the second section, intervention studies that focus on cognitive-behaviora strategies are reviewed. The third section reviews studies that employ h~~osis and studies that compare h~notic inte~e~tio~s to cognitive behavioral techniques. In the final section, methodologicai issues, conclusions and directions for future research are discussed. methods that
A primary debate in clinical practice concerns the issue of what role pharmacologic treatment versus co~itive-shalom methods shouid play in the dearest of procedural distress. A subcommittee on procedural pain from the Consensus Conference on Management of Childhood Cancer Pain” recommends aggressive pha~aco~o~i~ mana~eme~&, i.e., conscious sedation or general anesthesia, for the initial BMA and LP. For children under 5 years of age, they recommend conscious sedation or gene& anesthesia for all subsequent procedures. For children older than 5 years, they suggest an indi~dualized approach using behavioral and pharmacologic interventions alone or in combination.” These recommendations followed the observation that painful procedures were not being managed effectively or consistendy at many hospitals and oncology centers6 A survey of 29 Pediatric Oncology Group (POG) institutions indicated that 20% never used drugs for BMAs and 34% never used drugs for LPs.’ Of the 68% and 59%, respectively, that sometimes used drugs, the most commonly used were a combination of intramuscufar meperidine, promethazine, and chlorpromazine (so-called DPT) or chloral hydrate given by mouth. The sedative effects of the promethazine and chlorpromazine make this combination of drugs unacceptable for a number of children. Some children report feeling *‘out of control” and so sieepy that they cannot cope with the procediire.2,n They may be combative during the procedure acd sleep for several hours afterward, which often interferes ~th their return to norma! activities. fn addition, profound respiratory depression was reported in four 695 patients given DPT.”
and ~e~~~~ anes used for pa~nf~~ procedures in are becoming more widely used in erica. SpWifiCLdly, intravenous mim alone, or in Combination with an analgesic such as fe~~ny~ has proven to be safe and effective for controlling pain and distress.‘U Midazolam produces effective sedation of short duration, anterograde amnesia, and anxiolysis, with relatively few adverse effects.1”J2 Children are very reiaxed but easily aroused, with intact airway reflexes. The major risk ~oc~ated with mid~o~am is ~~ove~~~ation and subsequent bypoxemia. Careful monitoring of the patient, access to supplemental oxygen, resuscitation equipment, and personnel skilled in pediatric airway management are essential. Protocols for administering conscious sedation usually specify that someone be designated (e.g., a rmrse) to monitor airway patency, viral signs, and oxygen saturation during the procedure and the recovery phase, which usually lasts about 6c) min. The decision to offer conscious sedation for procedural distress is, in part, contingent upon the availability of the appropriate equipment and personnel. The potential for complications is underscored in a case report of a I4monthold patient who experienced signi~cant respiratory depression and cyanosis follo~ng the administration of fentanyl and midazolam.‘” The lack of cardiorespiratory monitoring and pulse oximetry delayed intervention until the child became visibly cyanotic, further complicated by the lack of supplemen~l oxygen at the bedside. The point of the case report was not to highlight the dangers of conscious sedation rather to emphasize its safety, given the appropriate technical and professional support. Current research has been directed at dete~ining the safety and efficacy of conscious sedation protocols that could be implemented by oncologists or nurses. ‘2 Otherwise, the impracticality of having an anesthesiologist present for every procedure might preclude the use of conscious sedation by smaller hospitals and oncology centers. The minimal pharmacologic interven!ion fOr au LP or BMA is a local anesthetic at the site. prior to the approval of an anesthetic r earn (E&&A), this involved a needlestick, which many children find distressing. EhKA is a eutectic mixture of local anesthetics that ~~~scio~s
se~a~~~
98
Ellis and Spanos
effectively alleviates needlestick pain. EMIA has been used with adults for dermatologic procedures and with children primarily for pain associated with venipunctures. In two controlled studies, EMIA was more effective than either a placebo, or no treatment for decreasing pain associated with lumbar puncture in 18 children.14
Factors Afecting Pain and Distress The terms behavioral anxiety, procedural distress, and distress are used to describe a complex interaction of cognitive, affective, and behavioral responses to a situation that involves pain. It is often impossible to separate pain from the anxiety and fear that children experience during a medical procedure. A host of factors contribute to the overall unpleasantness of the situation, including the unpredictability and the loss of control that are part of being restrained and forced to submit to a painful procedure. One of the benefits of conscious sedation is that children do not remember the procedure, are comfortable and relaxed, and thus do not get into a cycle of increasing anxiety with each procedure. A distinct disadvantage of sedatives such as chloral hydrate or promethazine and chlorpromazine is the accompanying drowsiness in combination with anxiety and fear, all of which tend to augment the feelings of losing control for some children. Children are not equally distressed by medical procedures. A substantial number declined participation in the intervention studies and expressed confidence in their own abilities to manage the pain and anxiety associated with procedures. Zeltzer and I_eBaron’” found that 12 (27%) of 45 children, and Jay and colleague@ found that 14 (16%) of 87 children asked to participate in an intervention study reported no need for additional help in coping with BMAs or LPs. Hilgard and IeBaront” offered 63 children the chance to learn hypnosis to control procedural distress, and 24 accepted the offer. The other 39 children (62%) felt they were coping well and did not need assistance. Factors that contributed to the variability of pain and distress behavior included the age and gender of the child,' St4 the level of parental anxiety, the parents’ anticipation of their child’s pains generalized fear of medical procedures, and coping style.17
Vol. 9 No. 2 Februay 1994
A number of investigators reported differences in the intensity and types of children’s distress behaviors as a function of age and children overall scored gender. Younger higher on measures of distress,‘+s:R*lsexhibited more types of distress behaviors (e.g., crying, screaming, refusal to hold the position, flailing, and clinging), over a greater time period, than did older children.’ Around age 7 years and older, children exhibited more behavioral control and tended to express their pain and fear verbally.” They were more able to articulate their fear and ask for support. Although younger children consistently exhibited more overt physical manifestations of distress, lack of behavioral control was not always correlated with self-reports of pain.s For some children, combative or active behaviors may be distracters that enable them to attend away from the procedure, which in turn may alter their perception of the intensity of the pain. Although their active behaviors are classifled as indicators of distress on many observational tools, their self-reported pain may be relatively low. In such cases, both self-reports of pain and behavioral assessments are essential to provide a complete picture of the children’s experience. Gender differences in behaviosal distress have not been as consistently reported as age differences. Katz and colleagues’ reported that girls scored higher than boys and were more likely to cry, cling, and request emotional support, whereas boys were more likely to engage in stalling behaviors. A number of other investigators, 5.8*18however, reported no difference in overall distress or types of distressrelated behaviors as a function of sex. Research to determine what effect children’s coping style has on pain perception and distress has provided mixed results. Typically, behaviors, attitudes, cognitions, etc., are dichotomized into opposing categories and used as a labeling variable. The lack of clear evidence for a definitive link between coping style and distress may be, in part, due to the difficulty of neatly summarizing the complexities of a multidimensional, interactive process that typifies coping. Hubert and colleagues’!) conceptualized coping style along the dimension of approach or avoidance based on the child’s request for information about the BMA. Children that
Ir,L 9 NQ. 2 FebnraT
1994
~ognilirle-~ellazlioral
actively sought information, participated in practice demonstrations, and listened to preparatoty information about the BMA or LP were considered to have an approach style of coping. Avoiders were uncooperative and uninterested in preparatory activities before procedures. They found no relationship between distress scores and informa~o~-seeking disposition in patients undergoing LPs and BM,As. Smith and colleaguessU used a similar approach-avoidance dichotomy and then matched the child’s coping style with an intervention they believed best suited to that style. The interventions consisted of distraction or information about the sensory aspects of the BhfA or LP. They found no difference in distress scores or self-reported pain between the two groups, and no support for the idea that a “goodness of fit” between coping style and the interventions would produce greater pain and distress reductions. Broome and colleaguesi found that children who displayed active or actionoriented coping behaviors (i.e., asked questions, attempted to control, and resisted) reported less pain during lumbar puncture than children who used passive coping behaviors (i.e., ignored staff, remained silent and motionless, and cooperated without complaint). F_elatedly, Hester*’ found that children who fought and cried during immunization reported less pain than children who passively complied. An appropriate intervention for this group of children might be to keep *hem informed of the progress of the procedure so they can scream at the appropriate moment. In this way, encouragement and praise for “good screaming” may validate the child’s efforts to take control of the situation.
Jay and colleagues s~s~*-s4conducted a series of studies that systematically examined distress behavior, antecedent variables and the effects of behavioral and pha~acoiogic inte~entions on procedural distress. In their first study, they designed and piloted a cognitive-behavioral therapy (CBT) package that was based on a stress-inoculation model.“2 Stress inoculation refers to a set of procedures that provides the
Interventions
99
individual with imaginative and cognitive strategies for pain reduction. Motivational instructions, i~fo~atio~, and Opportunities to pmctice the s~tegies form a multidimens~o~a~ package designed to help the in&vi&la] cope. PBThe CBT package consisted of attention diversion, reinforcement, imagery, behavioral rehearsal, and filmed modeling. Five children aged 3-7 years, referred for severe anxiety and behavioral distress related to BMAs and LPs, reduced their distress scores after iute~entio~ by at least 50%, The next study was a ~ompa~so~ of the CBT package with oral diazepam and an attentionCOINI-01condition (30 min of cartoon watching prior to the BMA) delivered in the context of a repeated-me~ures, counterbalance design.” A total of 56 children with leukemia, aged 3-13 years, were assigned one of six possible sequences with the stipulation that subjects given each sequence were equally proportioned according to age, gender, and previous experience with BMAs. Dependent variables were scores on the Observational Scale of Behavioral Distress (OSBD), self-reported pain, pulse, and blood pressure readings. Overall, children had significantly lower pain ratings, OSBD scores, and pulse rates when in the behavior-therapy condition as compared with either the diazepam or the attention~~ntrol group. Diazepam was useful for lowering anticipatory distress but had no effect on distress during the procedure (encounter phase). In fact, there was no difference between treatments in OSBD scores when the encounter phase of the BMA was analyzed separately. Considered to be the most painful, this phase includes cleansing of the puncture site, instillation of local anesthetic, and aspiration of the bone marrow. The lack of difference between treatments in the encounter phase of the BMA serves to highlight the complexity involved in evaluating the clinical relevance of a ~ha~o~l intervention. Collapsing across phases and comparing the total scores may lead to an overestimation of the usefulness or misapplication of the behavioral strategy. An intervention that appears to be effective overall may actually be most effective when used to manage distress in the anticipatory and recovery phases of the procedure. A different type of intervention may be needed to manage the more intense sensory experience of
100
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Ellis and Spanos
phase of the BMA. However, an improvement during the anticipatory and recovery phase may still be a meaningful improvement to the experience overall. It is interesting that no main or interaction effects were found for the sequence of the intervention. This implies that coping sttategies learned in the behavior-treatment condition were not used in subsequent BMAs where children were not specifically told how to cope. Similar findings were obtained in other studies. Dalquist and colleagues2s and Blount and colleagues27 reported that a majority of children undergoing a BMA or LP did not engage in coping strategies unless prompted to do so by an adult. In a laboratory setting, Spanos and colleaguesss demonstrated that subjects often refrained from using coping strategies unless explicitly told to do so. Subjects given the simple instructions “do whatever you can to reduce pain” showed greater pain reduction than controls given no instructions and equivalent pain reduction to a group given a coping suggestion. A limitation of both of the studies by Jay and of the colleagues’s~2z was the confounding behavioral treatments with support and coaching from the parent and/or psychologist. What constitutes professional or parental support and coaching should be made explicit. As reporied, this was an uncontrolled variable and may not have been consistent among all subjects, yet support and coaching may be salient factors in the effectiveness of the intervention for reducing distress. This needs to be examined more closely and systematically varied to determine what portion of the variance in distress scores is due to the intervention (i.e., distraction, imagery, etc.) and what is due to parental or therapist coaching and support. Perhaps it is the interaction of coaching and coping strategies that is most effective for reducing distress. The effectiveness of the oral diazepam for reducing anticipatory anxiety and the CBT package for reducing distress prompted Jay and colleagueG4 to examine the combined effects of oral diazepam and CBT, Within a repeated-measures factorial design, 83 children aged 3’/~12 years were assigned to either a CBT or CBT-plusdiazepam condition. Both groups reduced their OSBD and self-reported pain scores after the intervention; however, the
Vol. 9 No. 2 February 1994
CBT-plus-diazepam group had only one-third the reduction as compared with the children in the CBT-alone group. The investigators suggested that the diazepam may have interfered with the learning of the cognitive-behavioral strategies. In addition, the children may have been unable to remain focused on the imagery and distraction tasks during the procedure due to the effects of the diazepam. Parents of the children in the CBT plus diazepam study were offered an intervention to decrease their own stress resulting from their child’s painful medical procedures.“” Data from previous parent interviews” indicated that parental anxiety was positively correlated with the children’s procedural distress. A stressinoculation intervention specific to the needs of the parents was offered to one group of parents, with the second group simply observing their children undergoing the CBT program. The stress-inoculation group demonstrated larger decreases in state and trait anxiety from baseline than did the observation group. The decrease in anxiety for the parents, however, had no effect on the children’s behavioral distress or self-reported pain.
Procedures labeled as “hypnotic” have been employed for over a century to reduce pain associated with a variety of medical conditions. Hypnosis has been used for pain control with children experiencing headaches, burns, chronic recurrent abdominal pain, and sicklecell crisis. Most of the evidence for the effectiveness of hypnotic procedures is anecdotal or based on case reports. The few controlled studies have been done with children undergoing BMAs or LPs. Theoretical controversies concerning hypnosis center around the assumption that hypnosis is associated with a particular psychological or physiologic state that can be readily recognized and reliably produced with an induction ritual. Typically, a hypnotic induction contains suggestions for relaxation, sleepiness, eye closure, and suggestions for entering hypnosis. Substantial research has failed to identify physiologic, behavioral, and verbal report indicators that unambiguously reflect an hypnotic siate (as opposed to relaxation, expectancy-induced behaviors, etc.).E1-st
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Cognitive-Behavioral Intenmtiow
Traditional interpretations of hypnotic analgesia view the induction procedure and the assumed hypnotic state as critical for pain reducti0n.s~ According to ~iI~rd,~~~ b~~~t~c analgesia is the result of an amnesialike process that involves the dissociation of pain from phenomenal awareness. Consistent with this hypothesis, only highly h~~otizable subjects {i.e., those that score high on scales that assess responsiveness to a standardized series of hypnotic suggestions) possess the ability to dissociate and thus experience high levels of h~nodca~y induced pain reductio~.~~ An alternative perspective conceptualizes hypnotic responding as continuous with other types of complex social behavior. According to this view h~notic responding can be accounted for by using constructs regularly employed by social and cognitive psychologists to explain other forms of social behavior (e.g., attitudes, expectaGons, interpretations, role enactment, and self-e&a+. ~~notic sub jects are viewed as performing goaldirected actions based on an understanding of the demands of the situation. From this perspective, hypnotic analgesia does not occur automatically and i~vQiun~~ly. Rather, it is the result of the individual actively engaging in cognitive activities to ameliorate the effects of the noxious stimulation. According to this perspective, subjects low in b~notizabili~ can be induced in various ways to reduce pain to the same extent as highly hypnotizable subjects (for a more complete discussion, see Spanos and ChaveG4f _ A number of intervention studies examined the effectiveness of hypnotic interventions, or compared such interventions t.o other cognitive-behavioral strategies for relieving procedural pain and distress. It is difficult to compare studies that employ hypnotic i;lterventions because there are no standardized procedures in the clinical use of hypnosis that define a situation as hypnotic. In the laboratory pain literature, the term hypnotic analgesia condition refers to a standardized induction followed by a set of standardized imageq-based analgesia suggestions. Nonhypnotic condition refers to the same analgesia suggestions without the initial hypnotic induction. In the clinical studies reviewed, there were a variety of di@erent procedures labeled hypnotic that included some combination of an’ induction,
101
breathing exercises, istraction, imagery, suggest.ion, and therapist support. There was no s~~dardizado~ across the studies, however, and in several studies t e procedures were never defined as hypnotic to either the patients or their parents. Milgard and LeBaronui were among the first i~ves~~to~ ~stemadc~ly to study the use of hypnotic procedures for alleviating procedural distress. A total of 24 children (aged 6-19 years) participated in a hypnotic intervention that consisted of eye fiation and closure, followed by suggestions for relaxation, imagery, and the suggestion for comfort during the BMA. The therapist directed the children through a rehearsal of the BMA and acted as a coach during the actual procedure. Overall, there was a statistically significant reduction in self-reported pain, and observer-reported pain and anxiety, after the hypnotic treatment. Subjective pain ratings decreased from a mean of 7 prehypnosis to a mean of 5 after hypnosis. Keller-man and colleagues4 studied the effect of an hypnotic intervention that consisted of an induction technique, rhythmic breathing, suggestions for progressive muscular relaxation, increased well-being, and visualization of a favorite or special place. A total of 16 adolescents, preselected for high levels of procedural distress, were taught self-hypnosis and given the opportunity to practice it prior to a procedure. During the BMA or LP, “additional suggestions for enhanced comfort were g-*hen” (p. 87). Neither the role of the hypnotherapist during the procedure nor how much of the intetvention was self-hypnosis as opposed to therapist directed is clear. Consequently, it is difftcult to interpret the effect of attention or support on pain and distress. All 16 adolescents showed a significant reduction in self-reported pain and anxiety from baseline to posttreatment. As the authors point out, the data do not establish which aspect of the treatment was most effective for reducing distress. The lack of a control group makes it difftcult to attribute the change unequivocally to the treatment. The attention and support from the therapist prior to, and possibly during, the procedure may have been a factor contributing to the reduction in distress. Katz and coileaguess” compared hypnosis with an attentioncontrol treatment (unstructured play sessions prior to the BMA) with 36
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Ellis and Spanos
subjects, 6-12 years of age. The hypnotic intervention included an induction, muscle relaxation, imagery and suggestions related to coping with the sensory-pain aspects of the Suggestions for practicing and experience. reentering hypnosis when cued by the therapist were included during a series of training sessions. Roth groups showed equivalent reductions in self-reported pain and fear from baseline measures, but the pain scores consistently increased from first to third BMA. Distress scores between groups were not signilicandy different, with children in both groups exhibiting increasing distress from baseline to the third BMA. The children were expected to transfer information learned during the hypnotic training sessions to the bone marrow procedure independent of coaching from the therapist. This may have been too much to expect from the children given the magnitude of the anxiety and distress typically associated with these procedures. In fact, the presence of the therapist without attempts to aid in coping may have been frustrating for some of the children and may have actually increased their distress. Related clinical research with childrensse**7 and laboratory research with adultszs has shown that individuals are more likely to use coping strategies if prompted to do so.
Cognitive Strategiesversas ~y~~~ Three studies have compared cognitive strategies with hypnotic interventions to determine the method most effective for reducing procedural distress. Zeltzer and LeBaron’s compared a combination of deep-breathing exercises and nonima~nal distraction activities (e.g.. hand squeezing, talking, and counting) with treatment that included therapist-assisted deep breathing and pleasant imagety that the investigators labeled as hypnotic. The imagery-based strategy was not defined as hypnosis to either the children or families, however, and did not include a h~notic-induction procedure. Tbus, it is more accurately described as a guided imagery treatment than a hypnotic treatment. Both interventions were effective at reducing the pain ‘N4.s and the anxiety associated with LPs. rniitnough Zehzer and I..eBaron’s argued that hypnosis was more effective than a nonhypnotic treatment for reducing pain and anxiety, it is
Vol. 9 No. 2 February 1994
more accurate to conclude that, in their study, guided imagery was more effective than distraction for reducing pain and anxiety. Wall and Womack”” compared a hypnotic treatment that consisted of an induction procedure, relaxation, and visual imagery with a nonhypnotic distraction procedure. The ages of the 20 children in the study varied from 5 to 18 years. Both inte~entio~s were equally effective for reducing self-reported pain, but neither intervention had an effect on anxiety. Kuttner and colleaguess7 compared distraction, a procedure labeled hypnosis/imaginative involvement, and a standard practice control group, in the reduction of procedural pain and distress during BMA in 30 children, 3-10 years of age. In the distraction intervention, a therapist engaged the children in blowing bubbles, counting, puppet play, and looking at pop-up books during the procedure. The hypnotic group received a combination of hypnotic suggestion, guided imagery, and therapist support. Following treatment, each child was assessed during two B&Us. The only significant finding to emerge indicated that, among younger children (3 years to 6 years 11 months), the hypnotic treatment produced lower distress scores than did the distraction or control treatments in the first BMA only. By the second BMA, the younger children in the three groups showed equivalent reductions in distress scores. There was no significant differences in self- reported pain and anxiety among the three groups. In the hypnosis studies reviewed, it is difIicult to interpret the reductions in pain and distress as attributable specifically to the hypnosis and not some other aspect of the intervention. For example, in the study by Kuttner and colleagues,“’ the hypnosis group used imagery, suggestion, and therapist support while the control group used bubble blowing, counting, puppet play and pop-up books. To compare precisely the effects of hypnotic procedures on distress it would have been more useful to have both groups engage in the same activities, e.g., bubble blowing, pop-up books, guided imagery, etc., with these activities preceded in one group by the hypnotic induction. Any differences between the groups could then have been unambiguously attributed to the one variable that differed between them, the hypnotic-induction ritual.
In adult ~a~o~t~~ and clinical studies that separated the induction from the suggestions, imagery, distraction, etc., results consistency indicate that psycbolo~c~ treatment in the absence of hypnotic induction are always at least as effective as the same psychol~~c~ ~e~~~n~ preceded by hypnotic induction.gK-41 Three studies1G-35”6 examined the relationship between h~~oti~bi~i~ and pain relief during BMA. Hilgard and I_eBaron’C’ reported a sig~~~nt relations~p between these variables, whereas Katz and colleaguesS5 and WaII and Womack~6 found no rela~ons~ip between the variables. Similar inconsistencies bave been found in the adult clinical literature concerning the relationship between h~notizabiIi~~ and pain reduction. Taken together, these findings suggest that the relationship between hypnotizability and pain reduction is mediated by other variables (see Spanos and colleaguesJz for a review) _ Consistent with these adult clinical and laboratory studies, the pediatric clinical studies seem to indicate that hypnotic procedures provide no added benefits to those achievable with distraction, imagery, etc. Due to the imprecision with which the consltruct ofhypnosis was operationalized and lack of standardization across studies, however, it is impossible to draw definitive conclusions. While it is tempting to conclude there appears to be no clear benefits to hypnosis, the term should be clearly defined and unambiguously implemented in pediatric clinical studies before this can be concluded.
Taken together, the results of these studies (see Table 1) support the findings of numerous laboratory pain studies that indi~du~s can gain at least partial control over discomfort by controlling and directing their cognitive activities. A variety of interventions such as unstructured play, cartoon watching, relaxation, distraction, imagery, and hypnosis comprised interventions that helped children to cope with pain and anxiety. Most interventions were presented as muiticompone~t packages and were evaluated in terms of their overall effect on pain and distress. Questions remain as to which aspects of the interventions are useful ove;rail, or more appropriate for a specific
at the specific components of these ages and what effect the i~te~e~tio~ has OIJ the different phases of the aversive procedures. ~~teresting and relevant i~f~rrna~o~ has atso been uncovereJ during the process of ~de~d~ng ir~di~duals who are highly distressed by procedures. In searching for “volunteers,” investigators have found a group of chiIdreR that refused the offer to ~ar~cipate because they felt they were coping well on tbei~ CBW. St~d~~g this group of natural ‘“capers” might help in determining the variables that mediate successful coping. What a~~t~des, motivations, ex~ec~~o~s, and cognitive skills do these children have that enable them to manage successfully adopt as&stance? A growing body of literature on adult pain suggests that distraction and imagery work, in part, by encouraging coping cognitions and diminishing catastrophizing.4g*44 Ca~~opbizing refers to the tendency of individuals to focus on and exaggerate the negative aspects of the noxious situation, and the tendency to feel ove~heImed and unable to cope or control the situation.44+45 The natural capers appear to be at one end of a continuum that is balanced at the other end by children who reported high Levelsof pain and distress even after i~te~ent~o~s. For exampleJay and coIleaguesz4reported that, on a bpoint scale, 34% of 83 subjects rated their pain as a 4 or 5 and 24% rated their fear as a 4 or 5 postintervention. Do these children f?t the profile of the catastrophizer as described in the adult pain literature? What variables or cognitive activities differentiate these children from those who cope well on their own and those who successfullyuse the psychological interventions to reduce pain and distress. It is clear that not all children do equally well using psychological analgesia, but the reasons for this have yet to be empirically described. It may be that some children, similar to some adults, are able to genera&e imagery and distraction coping strategies spontaneously to reduce their distress. Other children may continue to catastrop&e even when prompted to use imagery or distraction. There is some evidence that the lack of ca~~o~hizing cognitions determines pain reduction more so than the presence of coping cognitions.4f’
Baseline-posttest
Repeated measures counterbalanced
hei 3-7 yr
M56 3-13 yr
AW3 3.5-12 yr
&72 Parent of children in previous study (79% mothers)
i-24 6-19 yr
W16 11-yr
Jay and colleagues**
Jay and colleague@
Jay and colleaguesV4
Jay and Elliot”
Hillgard and LeBaronlG
Kellerman and colleagues4
Baseline-posttest
Baseline-posttest
Repeated-measures factorial
Repeated-measures factorial
Design
Patients
Investigators of intervention
CBT package CBT package plus oral valium
Intervention: hypnosis = (induction) eye fixation or hand levitation, rhythmic breathing, suggestions for relaxation, increased well-being, visualization of a favorite place, posthypnotic suggestion for comfort and mastery during the procedure
Intervention: hypnosis = (induction) eye fixation and closure, suggestion for relaxation, imagery, posthypnotic suggestion for comfort during BMA
Intervention: stress-inoculation procedure = film about cancer and helping children cope with procedures, relaxation training, and positive self-statement training. Control group: parents accompanied their children during CBT training
Intervention: Intervention:
Intervention: CBT packaged as described above. Intervention: oral valium Control: 30 min of cartoon watching
Intervention: cognitive behavior therapy (CBT)= breathing exercises, trophy as reinforcement, imagery, behavioral rehearsal, and film of child successfully coping with bone marrow aspiration (Bm)
Description
Table 1 Comparison of Intervention Studies variable
Self-reported pain and selfreported anxiety
Self-reported pain and observerrated anxiety
Parent behavior scale, state-trait anxiety inventory, selfstatement inventory for medical procedures, selfreported coping diffhzulty, pulse, and blood pressure
OSBD scores, and self-reported pain
OSBD scores, self-reported pain, pulse, and blood pressure
Observational scale of behavioral distress (OSBD)
Dependent
Significant reduction in pain and anxiety from baseline to posttreatment
Significant reduction in observer-rated anxiety and self-reported pain from baseline to posttreatment
Stfesdnoculation group showed greatest decrease in state-trait anxiety from baseline to time 2 No other significant difference
Both groups reduce OSBD and pain scores, CBT plus valium, less reduction then CBT alone
Lower OSBD scores, pulse rates, pain scores when in CBT intervention as compared with cartoon watching or oral Valium all three groups had equivalent OSBD scores during encounter phase of BMA
50% reduction in OSBD scores after intervention
Results
,I,
8.
,”
,,, ,, ,, ,
,,
8,
,,,, .,,/
,,*,,
,“,,I
,”, ,,,,,,
Intervention: hypnosis = (induction) arm levitation, relaxation, visual imagery, cued to use hypnosis with taped tnessage Intervention: some type of disuacdon strategies to shift attention away frottt the procedure
Repeated-measures factorial
IV=20 5-18 yt
Wall and Womack!t”
,,,,,
No significant difference in distress scores for older children, younger children itt hypnosis/imagery groups had lower distress scores on first BMA only, tto significant difference in pain and anxiety among groups
PBRSr, obsenver-rated anxiety, observer-rated pain, selfreported pain, and selfreported anxiety
Intervention: distraction (bubble blowing, pop-up books, puppet play, deep breathing) Intervention: imaginative involvement/ hypnosis = suggestions for time reduction, analgesia using a pain-switch technique, and itnaginative stories Control condition: information about the procedure, reassurance during the procedure
Repeated-measures factorial design
IV=30 3-10 yr
Kuttner and colleagued7
,m”.
>.,,
,,<,,,
,,
,,
.
Both interventions effective for reducing pain but not anxiety No difference in paitt or anxiety reduction lhetweett groups
BMA pain significantly reduced in both treattttcnt groups, anxiety reduced in hypnosis/itnagcty group only Lutnbar puncture (LP): pain significantly reduced in hypnosis/itnagety group only, anxiety significantly reduced in both treatment grottps. Overall hypnosis,‘itnagety associared with grenter reduction in pain and anxiety than distraction
Self-reported pain and selfreported anxiety
Intervention: hypnosis = described as therapist-assisted itnagety Nonhypnotic condition: deep breathing, distraction (counting, hand squeezing, and talking)
Repeated-measures factorial design
hF_33 6-17 yr
Zeltzer and LeBaront”
Self-reported anxiety, selfreported pain, observer-rated pain, and observer-rated anxiety
No significant diflerence in distress between grottps, distress scores increased frotn lirst 10 third BMA, equivalent reductions in self-reported pain and fear from baseline to posttreatment in both groups, consistent increase in scores from first to second BMA
Procedural Behavior Rating Scale-Revised (PBRSr), nurse rating of anxiety, self-reported fear, self-reported pain, therapist-patient rapport ratings, and response to hypnosis ratings
Results
httervetttion: hypnosis = (induction) eye fixation with or without eye closure, imagery, tnttscle relaxation, and suggestion related to coping with sensoty aspects of Bh4A Posthypnotic suggestion for reentering hypnosi.; with cue frotn therapist Control: unstructured play sessions prior IO BMA
variable
Repeated-tneasrtres factorial design
Dependent
AF-36 6-12 yr
of intervention
Katz and colleagues!‘s
Description
Patients
Investigators -
Design
Table 1 (continued) Comparison of Intervention Studies
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Ellis and Spanos
The studies reviewed focused predominantly on outcome, i.e., the reduction of pain and distress. Future research might profitably be directed at determining the individual or situation variables that mediate reductions in pain and distress. For example, patient-therapist relationship variables may be important in influencing children’s response to psychological interventions. Katz and colleagues’ reported a negative correlation between selfreported pain and therapist-child rapport during training sessions and a posttreatment increase in distress that could have been influenced by the minimal therapist support during the encounter phase of the BMA. Motivation and self-presentation are variables that may facilitate the process of learning and applying coping strategies. For example, motivation to present oneself as strong, competent, and able to manage may be an important factor in determining a child’s willingness to learn coping strategies and master the painful situation. The children who have both the motivation and the facility to use imagery and distraction may need only reinforcement for work well done. Other children may initially need a combination of motivational information and uraining, but can then use the strategies on their own, while another group ~rl?y need support to maintain motivation and strategy ‘use. If certain children are unmotivated to master the situation and uninterested in learning coping strategies, then this group might be appropriate candidates for the use of conscious sedatic .I during every procedure. The choice of whether to use cognitivebehavioral strategies or ronscious sedation is an issue that deserves some attention. The ideal situation would be to have both treatment modalities available, so that choices could be made based on the age and preference of the child and family. Some centers are not equipped to offer conscious sedation, however, and some children feel the benefits are outweighed by the inconvenience. Conscious sedation adds a considerable amount of time and technology to what are otherwise two relatively simple procedures. When such sedation is employed, children typically are allowed nothing by mouth for at least 4 hr before the procedure. During the procedure, they are monitored with a cardiorespiratory monitor and an oxygen saturation monitor, numerous
Vol. 9 No. 2 February 1994
sets of vital signs must be monitored, and the patients must wake up fully before they are allowed to leave the clinic. For some children and families, this added inconvenience outweighs the benefits of decreased pain and distress. The fact that children around age 7 years are better able to articulate their fears and communicate their need for support and control’ could be used as an age guideline for introducing the idea of choice to the child. Younger children might be given conscious sedation for all procedures and older children might opt to try distraction or imagety, initially for LPs (the less painful of the two procedures) and then, if successful, during BMAs. The particular strategy, i.e. blowing bubbles, counting, imagining, screaming etc., is probably not as important as children understanding what works best for them, and what amount and type of support they need from the people around them. “What can I do to help you make it through?” is a question that needs to be carefully considered and could form the basis of a written action plan to be used during procedures. The plan could be updated and augmented as children discover the right mix of activities and support that enable them to cope. Careful consideration of the child’s perspective on his or her own ability to cope is essential. Because self-report remains the best way to assess the affective and sensory component of pain, it is not appropriate for physicians, nurses, or families to decide the child is “doing ok” without input from the child. Oncology nurses are in an excellent position to develop, implement, and evaluate the plan for coping with painful procedures. Increasingly, nurses are designated as “case managers” or “primaty nurses,” and, as such, deliver and coordinate care for a specified caseload of children. In this capacity, nurses develop rapport and trust with children and their families. Because a nurse is always at the bedside assisting during procedures, it seems a logical and costeffective use of existing resources to offer nurses the opportunity to become proficient in the use of psychological analgesia. A number of resources including books,47*4* articles,4!) video_ tapes?O and workshops are available to facilitate nurses’ understanding of these techniques. The best possible outcome for children who must undergo painful procedures will probably be
El. 9 No. 2 Febmar)r 1994
Cognitive-Behavioral Inhvmtions
achieved with some mixture of pharmacologic and behavioral support. Reliance on either alone will probably not meet the needs of all children.
@S
1. Katz ER, Kellerman J. Siegel SE. Beha~o~9 distress in children with cancer undergoing medical procedures: developmental considerations. J Consult Clin Psycho9 1980;48:356-365. 2. McGrath PJ, HSU E, Cappelli M, Luke B, Goodman JT, Dunn-Geier J. Pain from pediatric cancer: a survey of an outpatient oncology clinic. J Fsychosoc Oncol 1990;8:109-124. 3. Jay SM. Ozolins M, Elliott CH, Caldwell S. Assessment of children’s distress during painful medical procedures. Health Psycho1 1983;2:133-147. 4. Kellerman J, Zeltzer L, Ellenberg L, Dash J. Adolescents with cancer: hypnosis for the reduction of the acute pain and anxiety associated with medical procedures. J Adolesc Health Care 1983;4:85-90. 5. Schecter NL, Altman A, Weisman S. Report of the consensus conference on the management of pain in childhood cancer. Pediatrics 1990;86(suppl): 813-834. 6. Zeltzer LR, A&man A, Cohen D, LeBaron S, Munuksela EL, Schecter NL. Report of the subcommittee on the management of pain associated with procedures in children with cancer. Pediatncs 1990;86:826-831. 7. Hockenberry MJ, Bologna-Vaughn. Preparation for intrusive procedures using uoninvasive techniques in children with cancer: state of the art vs. new trends. Cancer Nurs 1985;8:97-102. 8. Jay SM, Elliott C, Katz E. Siegel SE. Cognitivebehavioral and pharmacolo~c interventions for children’s distress during painful medicai procedures. J Consult Clin Psycho1 1987;55:869-865. 9. Nahata MC, Clotz MA, Rrogg EA. Adverse effects of meperidine, promethazine, and chlorpromazine for sedation in pediatric patients. Clin Pediatr 198~2~55~560. 10. Holmes CM, Galletly DC. Midazolam/fentanyl: a total intravenous technique for short procedures. Anesthesia ?982,37:761-765. 11. Diament I%$& Stanley P. The use of midazolam for sedation of infants and children. Am J Radiol 1985;150:377-380. 12. Sievers TD, YeeJD, Foley ME, Blanding PJ, Berde CB, Midazolam for conscious sedation during pediatric oncology procedures: safety and recovery parameters. Pediatrics 1991;88:1172-1179. 13. Yaster M, Nichols DG, Deshphande JR, Wetzel RC. Midazolam-fentanyl intravenous sedation in children: case report of respiratory arrest. Pediatrics 19~,8~~~7*
IOP
14. Kapelushnik J, Rome G, Solh H, Greenberg M, DeVeber L. Evaluating the efficacy of EMLA in alleviating pain associated with lumbar puncture: com~a~son of open and double-blinded protocols in children. Pam ~~~4~3~-~4. 95. Zeltzer L, LeBaron S. Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during
painful procedures in chi’ldren and adolescents with cancer. J Pediatr 198~,16~:1032-1035. 16. IiilgardJR, LeBaron S. Relief of anxiety and pain in children and adolescents with cancer: quanutauve measures and clinical observations. Int J @iin ~xp Hypn 1982;30:417-442. 17. Broome ME, Bates TX, Lillis PP. McGahee Tw; Children’s medical fears, coping behaviors, and pain perceptions during a lumbar puncture. Oncol Nu,r Forum 1990;173361-367. 18. Jacobsen PB, Manne SL, Gorfinirie R, Schorr 0, Rapkin B, Redd WH. Analysis of child and parent behavior during painful medical procedures. Health Psycho1 1990;9:559-576. 19. Hubert
NC, Jay SM, Saltoun
M, Hayes M.
Approach-avoidance and distress in children undergoing preparation for painful medical procedures. J Clin Child Psycho1 1988;14;194-202. 20. Smith KE, Ackerson JD, Blotcky AD. Reducing distress during invasive medical procedures: re9ating behavioral inteNentions to preferred coping style in pediatric cancer patients. J Fediatr Psycho1 1989;14: 465-419. 21. Hester NR. The preoperational child’s reaction to immunization. Nun Res 1979;28:250-255. 22. Jay SM, Elliott CH, Ozolins M, Olson RA, Pruitt SD. Behavioral management of children’s distress during painful medical procedures. Behav Res Ther 1985;23:513-520. 23. Jay SM. Elliott CH. A stress inoculation program for parents whose children are undergoing painfuf procedures. J Consult Clin Psychoi 1987;58:7!%804. 24. Jay SM, Elliott CH, Woody PD. An investigation of cognitive-behavior therapy combined with oral diazepam for children undergoing painful medical procedures. Health Psycho1 1991;10:317-322. 25. Turk DC, Meichenbaum D, Genest M. Pain and behavioral medicine: a cognitive behavioral perspective. New York: Guilford, 1983. 26. Dahlquist LJ, Gil KM, Armstrong D, De Lawyer DD, Greene P, Wuori D. Preparing children for medical examinations: the importance of previous medical experience. Health Psycho1 1986;5:249-259. 27. Blount RL, Corbin SM, Sturges JW, Wolfe W, Prater JM, James LD. The relationship &tween adults’ behavior and child coping and distress during Bm/LP procedures: a sequential analysis. Behav Ther 9989;20:585-601. 28. Spanos NP. Hodgins DC, Stam HJ, G-n M. Suffefing for science: the effects of implicit social
108
Ellis and Spanos
Vol. 9 No. 2 Febmq
1994
demands on response to experimentally induced pain. J Pers Sot Psycho1 1984;46:1162-1172.
pore-mandibular pain and dysfunction Psychosom Med 1984;46:534-545.
29. Barber TX, Spanos NP, Chaves JF. Hypnosis, ima~nation and human ~tential~ties. New York Pergamon, 1974.
40. Spanos NP, Stam HJ, Brazil K The effects of suggestion and distraction on coping ideation and reported pain. J Ment Imagery 1981;5:7!%-90.
30. Edmonston WE Jr. Hypnosis and relaxation: modern verification of an old equation. New York: John Wiley and Sons, 1980.
41. Spanos NP, Ollerhead VG, Gwynn MI. The effects of three instructional treatments on pain magnitude and pain tolerance. Imagin Cogn Pers 1986;5:321-337.
31. Periini AH, Spanos NP. EEG meth~olo~es and h~noti~bili~: a critical review. Ps~hoph~iol~~ 1991;29:51 I-530. 32. Hilgard ER. The problem of divided consciousness: a neodissociation interpretation. Ann NY Acad Sci 1977;296:48-59. 33. Hilgard ER. Divided consciousness in hypnosis: the implications of the hidden observer. In: Fromm E, Shor RE, eds. Hypnosis: recent developments and new perspectives. Chicago: Aldine, 1979:45-79. 34. Spanos NP, Chaves JF, eds. Hypnosis the cognitive-behavioral perspective. New York: Prometheus, 198~2~2~. 35. Katz ER, Kellerman J, Ellenberg L. Hypnosis in the reduction of acute pain and distress in children with cancer. J Pediatr Psycho1 1987;12:379-395. 36. Wall VJ, Womack W. Hypnotic versus active cognitive strategies for alleviation of procedural distress in pediatric oncology patients. Am J Clin Hypn 1989;31:181-191. 37. Kuttner L, Bowman M, Teasdale M. Psychological treatment of distress, pain, and anxiety for young children with cancer. J Dev Behav Pediatr 1988;9: 374-382. 38. Edelson J, Fitzpatrick JL. A comparison cognitive-behavioral and hypnotic treatments chronic pain. J Clin Psycho1 19;45:316-323.
of on
33. Stam HJ, McGrath PA, Brooke RI. The effects of a cognitive-behavioral treatment program on tem-
42. Spanos NP, Carmanico S, analgesia: laboratory and clinical P, Melzack R., eds. Textbook Edinburgh: Churchill Livingston,
syndrome.
Ellis JA. findings. of Pain, 1994 (in
Hypnotic In: Wall 3rd ed. press).
43. Spanos NP, Perlini AH, Robertson LA. Hypnosis, suggestion, and placebo in the reduction of experimental pain. J Abnorm Psycho1 198~9~28~~3. 44. Spanos NP, Brown JM, Jones 8, Homer D. Cognitive activity and suggestions for analgesia in the reduction of reported pain. J Abnorm Psycho1 1981;90:554-561. 45. Sullivan MJL. Bishop SR. ~~trophizing and pain. I. Scale development and validation (unpub lished manuscript). Halifax: Dalhousie University, 1991. 46. Sullivan MJ, Rouse D, Bishop SR, Cutler, M. Catastrophizing and pain. II. Thought intrusions and affective correlates (unpublished manuscript). Halifax: Dalhousie University, 1991. 47. McGrath PA. Pain in children: nature assessment and treatment. New York: Guilford, 1990. 48. Zahourek RP. Relaxation and imagery: tools for therapeutic communication and intervention. Toronto: WE Saunders, 1990. 49. Heiney procedures.
SP. Helping children through Am J Nurs 1991;91:20-24.
painful
50. Kuttner L. No fears no tears: children with cancer coping with pain (video). Vancouver: Canadian Cancer Society, 1986.