PSYCHOLOG I C A L TREATMENT OF DISTRESS, P A I N AND A N X I E T Y FOR YOUNG

CHILDREN W I T H CANCER

Leora T a m a r K u t t n e r

B.A. (Hons. 1 . U n i v e r s i t y of W i t w a t e r s r a n d , 1973.

M.A. ( C l i n . Psy.), Un ivers i ty of S o u t h A f r i c a . 1978.

T H E S I S SUBMITTED I N P A R T I A L F U L F I L L M E N T OF

THE REQUIREMENTS FOR THE DEGREE O F

DOCTOR O F PHILOSOPHY

i n the D e p a r t m e n t

of

Psycho1 ogy

@ Leara T a m a r K u t t n e r 1984

SIMON FRASER U N I V E R S I T Y

S e p t e m b e r , 1984.

A l l r igh ts reserved. T h i s thesis m a y not be

reproduced i n w h o l e or i n part , by photocopying

or other means , w i t h o u t p e r m i s s i o n of the author.

Name: Leora Tamar Kuttner

Degree: Doctor of Philosophy

T i t l e of t h e s i s : Psychological Treatment of D i s t r e s s ,

Pain and Anxiety f o r Young Children

with Cancer

Examining Committee:

Chairperson: D r . Roger Blackman

D r . Marilyn Bowman

- - D r . Robert Ley

- D r . Wi 11 i am Kranc,

b+. Joan Pinkus

D r . E l i n o r Ames Al t e rna t e Member

D r . Samuel LeBaron External Examiner Department of P e d i a t r i c s Univers i ty of Texas Health Centre a t San Antonio

Date Approved: I~&Q'

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T it l e o f Thes i s / P e t / E - A w

P s v c h o l o ~ i c a l Treatment of D i s t r e s s , Pain and

Anxiety f o r Young Children with Cancer

Author:

(s ignature)

Leora Tamar Kuttner

( name

(da te)

ABSTRACT

Children aged three to ten years with leukemia who

were required to undergo painful bone marrow aspirations

and lumbar punctures, were g i v ~ n ane o-F three psychological

treatments to reduce the associated distress, pain and

anxiety. This study investigated the efficacv of

imaginative involvement. distraction and standard medical

~ractice for pain, distress and anxiety reduction.

One group received a hy~notic treatment,

imaginative involvement, in which the child's attention was

absorbed in a favourite story or adventure-fantasy which

included suggestions for comfort and pain relied. Ths focus

of the treatment was internal: to create a different

interpretation of the experience through the use of

imagination.

A second qroup was given a behaviuural treatment,

distraction, which shifted attention away from the painful

stimulus anto a variety of meaningful physical objects,

such as ~op-up books and squeezy toys. fils0 bubble blowing

was used to interrupt the crying and regulate breathing.

This focus here was external.

A third group continued with standard medical

practice and served.as the control group.

Objective ratings of distress. and judgement

ratings of pain and anxiety were obtained from the

ohysician, nurse. parent and two trained observers.

Se1-F-repart scores were obtained from the childrep.

Results showed di++erential treatment e++ects +sr

the ycunqer children (aged 3 k c e year5 1 1 months) and the

older children (aged 7 to 10 yearsi. At first intervention

the vounqer q r a w showed a significant reduction in

distress when imaginative involvement was used. In

ccntrast, the older group evidenced significant reduction

in pain and anxiety when both distraction and imaginative

invulvement were used. Differential aqe effects in the

distraction treatment indicated greater benefits far alder

children than younger. Wide individual differences were

a1 so observed.

No signif icant treatment effects were found at

first intervention on the self-report measures of pain and

anxiety. Hewever, at second intervention a1 l qroups showed

reduction in sel+-reported pain and anxiety, observed

distress and pain.

Imaqinative involvement appeared to have an

all-or-none effect which may be related to hypnotic

suscepti bi 1 i ty. Distraction appeared to rely on the

development o+ coping skills and seemed to improve with

practice. Both psychological techniques demonstrated

important benefits for children in medically taxing

situations.

Manv people part ic ipated, assisted and advised i n

t h i s research study. I could not have done without any of

them.

A t B r i t i s h Columbia ChildrenFs Hospital. my warm

thanks go t o Drs. Tony LePage and Mavis Teasdale fo r t h e i r

support in se t t i ng up and running the studv: t o D r

Sadaruddin, Jane Pengelly and the Oncol~gy out-patient team

f o r making me par t af the team: t o Diane Hobdav, Gerd-Elise

Johnson and J i 11 Flemons f o r t h e i r w i 11 ingness, s e n s i t i v i t y

and committment t o the project : and t o the ch i ldren and

t h e i r parents a t t h e - c l i n i c who shared d i f f i c u l t times wi th

me. and surprised and inspi red me with t h e i r couraqe.

My thanks extend t o Dr . Sam LeBaron i n San Antonio

Texas, f o r the i n i t i a l impetus t o proceed wi th t h i s

endeavour.

A t Simon Fraser Univers i ty I would l i k e t o express

deep appreciation t o my senior superv'isor Dr . Mar i lyn

Bowman f o r her e f f i c i e n t and thoughtful guidance. She was

t o t a l l y supportive and provided me wi th sound and simple

salut ians ta the problems of applied research.

I would a lso l i k e t o thank my committee members:

Dr . Bob Ley f o r h i s generous investment of time, i n s i g h t f u l

and thought-provoking comments and e d i t o r i a l s k i l l s ,

6

Dr. B i l l Krane fo r h i s expertise, thoroughness and many

hours in the quest for statistical coherence,

Dr. Juan Pinkus for her gaud judgement and suopart at all

times.

My thanks is also expressed to Juan Foster far her

willingness and skill in decoding the computer's mystifying

messages, and to m y Husband, Dr. Tom O'Shea who came into

my life at the beginning of this endeavour, and shared the

unf aldinq process and the jay of completion.

................................................... Approval i i

Clbstract ................................................... i i i

............................................ List af Figures xi i i

C ~ B P L E R - Q ~ E L ~ ~ L B ~ B ~ C I Z ~ N

Statement o# the Problem ................................... - 1

........................................ Purpose of the Study 2

..................................... Mortality Rates -4

Treatment and Management of Leukernia..................S

The Bone Marrow Aspiration Procedure.......................--5

Typical Eehaviours in Response ta BMAs................~

Typical Behaviours in Response to LFs.................~

Medical Sta+f Burn-out ..................... ..III....II~..IIIOo Pain: Conceptual Prob1ems...................................10

Pain in Children with Leukemia.......................ll

The Role of Psychological Intervention......................12

Assessment of Childhood Pain and Suffering ...........12

Psychological Techniques in the Management

............... of Childhood Pain and Suffering ...12

CHBP_IEE,LW_Q-r-EEvLSW_-QE-XHE_-hZIE,RA,LU_BE

Definitions and Concepts of Pain..........,.................15

v i i i

Theories of Pain and Suffering ............................ 17 ............................... Acute and Chronic Pain 19

Psychological Treatment af Pain and Anxiety ................. 20 Cognitive Approaches to Reducing Paln ................ 23

q- Adult Studies ................................ 1:. Children7s Studies ............................ 25

-b Individual Differences ....................... dB

Children's Individual DifSerences ............30

7- Behavioural Techniques ............................... -- Behavioural Theory on Pain .................. ..>a

Relaxation ................................... 34 Cognitive-Behavioural Variable.Distracticm ... 35

-- Definition and Process of Distraction ........ s/ -. Laboratory Evidence ...........................> 8

Children's Studies ........................... 42 ......................................... Hypnotherapy 49

Hypnosis and Pain Re1 i ef : Hi stor i cal

~verview .............................. 49 Laboratory Evidence .....................=.I.. 5 C )

...................... Hypnotic Susceptibility 52

Hypnotizability in Children .................. 55 Definition of Hypnosis in Children ........... 57 Clinical Studies of Children with Cancer .... -58

4 Comparative Study: Behavioural and

............................. Hypnotic Methods 65

............... The Present Study . ~ . . . . . . . . . . . . . . . . . . ~71

CYSPEE-LHEELEELHP~

.................................................... Subjects 72

Age ................................................ *.?5 ..................................................... Setting 76

Observers ................................................... 7s

Measures .................................................... 80 The Procedure Behavi or Hat i ng Scal e-Revi sed (PBRS-R) . 80 Anxiety and Pain Judgement Rating Scales ............ 82 Self-report of Pain and Anxiety ...................... S2

The Stanford Hypnotic Scale for Children (SHCS-C) .... 84 Procedure ................................................... a5

Group I: Standard Medical Practice (Control) ......... 85

Preparation phase for Group 11: Distraction ........A 7

Medical Phase for Group 11: Distraction ............. -88 Preparation Phase for Group 111: Imaginative

Involvement.. ................................ 89 Medical Phase for Group 111: Imaginative

Involvement ................................ ..9(3 Differences between the Two Treatments ............... 93

Design ...................................................... 94 CHAPTER FOUR: RESULTS

Results from the BMA Pracedure .............................. 95 Description o+ the PBRS-R Data ....................... 95 Distress: PBRS-R ..................................... 98

Pain ................................................ 102

.................. Judgement Ratings for Pain 102

........................... Self-Report Pain 1 0 8

........................................... finxiety =.11<3

Judgement Ratings for Gnxiety ............... 110 ........................ Self-Report Anxiety - 1 1 6

Correlations between the Pain Measures .............. 1 1 6 Correlations between the Anxiety Measures ........... l14 Correlations between PBRS-R, Self-report

and Age .................................. ..I19 ............................. Hypnotic susceptibility 120

.............................. Results +ram the LP Procedure 121

Description of the PBRS-R data ...................... 121

--% Distress: PBRS-R .................................... ILL

................................................ Pain j22

........................... Judgement Ratings 122

Self-Report Pain ......................... A 2

............................................. Anxiety 124

........................... Judgement Ratings 124

......................... Self-Report Anxiety I24

CYQPIES-ELVE ;-PLSCYSSAON

Baseline to First Intervention ............................. 126 .

Age and Treatment Effects ........................... I28

...................................... Older Children 1ZC)

.................................... Younger Children 13s

.............................. First and Second Intervention 137

The Process of Change ............................. ......... 14b

..................................... Individual Differences 142

Table I . PPRS-R Analysis of Covariance +or First

Table 2. PBHS-H Analysis of Covariance for First

and Second Intervention.........................103

Table 3. Ancova of Pain Hating for First

Intervention....................................lO4

Table4. Ancovaof Pain Rating for First

and Second Interv@ntion..........................lf)7

Table 5. Ancova of Self-report Pain for First

and Second Inter~ention..................~......l11

Table 6. Ancova of Anxiety Ratings for First

Table 7. Ancova of Anxiety Hatings for First

and Second Intervention............I.......I.I.1115

Table 8. Ancova of Self-Report Anxiety for First

and Second Inter~ention..................~......118

xlii

LIST O F FIGURES

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

Figure 7.

Figure 8.

Figure 9.

Dot Plot o+ the Younger Children" FPBRS-R scores

summed for the two observers at Baseline (b),

First (1) and Second Intervention (2). ......... -96 Dot Plot of the Older Chi ldren'5 PBRS-R scores

summed for the two observers at Baseline (81,

First (1) and Second Intervention(2). ........- -97 Interaction of Group and Age on Distress Scores

(PERS-R)~I~=~-~~s~.o.IIIIIIIII.I.I.l.I.I..IIIILIIII.o.IIIIIIIII.I.I.l.I.I..IIIILIIII.~~~m~m~---~~~*-~~~m~----lO1

Interaction of Group and Age on Judged Pain

at First Intervention..........-..~.......-..lO(S

Dot Plot o-F the Self-report Pain scores at

Baseline (B), First (1) and Second

Intervention (21..................-.-........1CT9

Interaction of Group and Age on Judged Anxiety

at First Inter~ention.......~.........~~.....l14

Dot Plot of the Self-report Anxietv scores at

Baseline (B) , First { 1 ) and Second

Intervention (2).........1......-..I....-...1117

LP scores: Interaction of Group and Age

............................ On PERS-R scores 123

Distress scores {PBRS-R) comparing First

and Second Inter~ention.........~..-....-~~~.125

CHAPTER QNE

INTRODUCTION

Statement o i t h z Pr~blem ------------------------ Prior to 1950 mast children with A r u t ~ Lymphorytfe

Leukaemia (ALL) died within a few months after the anset a+

the disease. by 1977 rapid advances in medical research had

altered this death sentence to a 50% mortality rate after + i v e

years from initial diagnosis ISchweers, Farner & Forman,

1977). The current medical treatment regimens far GLF include

frequent hospital visits, intensive chemotherapy and recurrent

painful procedures such as Bone Marrow Aspirations (BMAs) and

Lumbar Punctures (LPs). However once a positive response to

medical treatment has been achieved, another concern arises:

how to adjust to and manage a chronic malignant disease whizh

has an uncertain lonq-term outcome.

The onerous and aversive medical procedures ta:: the

young cancer patient's coping capacities (Jay & Elli~t, in

press; Kellerman, Zeltzer, Ellenberg & Dash, 1983; Koocher &

O'Malley, 1981; Spinetta & Maloney, 1975) .The strain is

evidenced by the high frequency oi psychological problems such

as needle phobias, anticipatory vomiting, qeneralized fear

resPonses to hospi tal , and depressi on (Katz , Kel 1 erman &

Sieqal , 1980: Olness, 1981 1. Researchers have examined the

impact of this arduous process on the psychalogical well-being

of children with cancer (Jay, Ozalins, Elliott b Caldwell,

1983: Katz, Kellerman & Siegal. 1980; Spinstta Maloney,

.-7 L

1975; Zeltzer. Kellerman. Ellenberg, Dash b Rigler. l98O). The

unanimous conclusion is that osycholagy has much t@ d f e r

pediatric oncology ~atients through the asse-ssment and

management a+ pain, anxietv and distress, thereby Increasing

the possibility that the child remains psyrhalogically intact

throuqhout the arduous treatment,

PI major source u+ anxiety and distress +or children

with leukemia is the regularly repeated BMAs a d LPs. These

d~agnostic and treatment related procedures arp frequently

perceived by the patlent5 as beinq worse t h s n the disease

itself (Zeftzer. Kelferman, Ellenberger. Dash, & H1gfer,lY80).

Furthermore, there is cotivincing evidence that over time most

children do not habituate to these repeated invasave

procedures, and that anxiety remains ubiauitous (Katz.

Kellerman & Siegal, 1980). Sainetta and M a 1 m - t ~ ~ (19751

indicated that the young patient's anxletv in attending the

outpatient clinic increased as the frequency o+ ~ i s l t s and the

duration of the illness increased. This anxietv Is alsc

frequently manifested in sleep and eating disturbances,

behavioural problems at home and management difficultlec Fn

hospital.

The medical methads that have been and cauld be used,

such as a general anesthetic nr sedation, have drawbacks.

Medical staff currently have the choice af perfarming the BMAs

and LFs with or without sedation. The sedation most commonly

used is Demerol given orally one hour grior to the pr~cedure. ' I

It is often not effective and results in a paradoxical

reaction in which the child is cognitivelv ' f u z z y ' vet

hyper-reactive. he need for other forms o+ management has

been recognized by a number of researchers in the +irld

fn the present studv the author investigated

osychol~gical methods that could be used concurrently with

medical procedures. These psycho1 ugi ral treatments were

designed to reduce pain, anxiety and distress be+ore and

durinq the pr~cedure, and to have no attendant r i s k s I n

application. This study focused on young children 3 to 10

years of aqe. The 3 to 5 year old grcup had not as vet been

the focus of any systematic treatment Investigation. The

purpose of the study was to determine whether ~~ycholouiral

methods of distraction and imaginal invglvement were ef+ertive

in reducing distress. pain and anxietv durinq EMAS and LPs for

the young cancer patient.

I k - P i ~ ~ s ~ e

Derived from two Greek words.'leukos7 which me2ns

white and 'emia' which refers to a condition uf the blucd.

leukemia rs a cancer of the blood-producing body tissues, the

bone marraw. spleen andfor f ymph nodes. It is manifested

through the overproduction o+ immature white blood cel1.s

(Leukocytes) which, by avercrawding, impede the production of

other blood cells. There are several types of leukocytes, the

main three are Neutruphils, Lymphocytes and Monocytes. Any of

t h e s e zolls c a n b e a i i e c t e d and i n s t e a d of m a t u r i n g t o assume

rertain s u q z t i a n s t h e y r e m a i n immature and r ~ n t i n u e t o

m u 1 t i c 1 .. The sccumul a t l a n and di s o r d e r l v q r a w t h a+ a b n ~ r ! n z 1

Leukomir ce l l s c a u s e s z w i d e = p e r t r u m of g o n ~ ~ - a L p h y s i c a l

symptoms t h a t m i m i c many c h i l d h o e d i l l n e c s e s . T h e ~.yrnpt?zrns

i n c l u d e t i r e d n e s s , ~ a L l a r , b r u i s i n g , f e v e r , b ~ n e p a i n a n d

g e n e r a l d i scamf ar t . B e c a u s e a+ t h e abnormal w h i t e cef 1s t h e

l e u k e m i c p a t i e n t is a l so p r o n e t o i n f e c k i a n s and r ecuc ie ra t i i on

i s ~ e v e r e l v i m p a i r e d .

T h e most ccmman I apprc tx ima te ly 60%) of t h e l e u k a e m i s s is t h e

l y m p h c c y t i r , lymphoid or l y m p h o b l a s t i c l e u k e m i a , known a s

& c u t e L y m p h o b l a s t i c Leukemia (ALL): its a n s e t and c o u r s e is

a c u t e and r a p i d .

T h e l e u k e m i a s r a n k as t h e h i g h e n t c a u s e (45.5%) c+ a l l

r h i l d h a a d cancer d e a t h s ISutow, V i e r t i 8~ F e r n b a c h , 19773. T h e

p r u g n u s i s a+ ALL h a s imprcwed s t e a d i l y and siqnif i c a n t l y c i n c e

t h e i n t r o d u c t i o n a n d c o n t i n u e d r e + i n e m e n t a+ mul t i m o d a l

t h e r a p y .

T h e h i g h e s t i n c i d e n c e a+ c h i l d h o c d l e u k e m i a I 5 i n

c h i l d r e n a g e d 3 t o 5 y e a r s o f agE. A n a l y s i s Q* t r e n d s i n ALL

s u r v i v a l i n d i c a t e that f o r c h i l d r e n aged 3 y e a r s d u r i n g t h e

p e r i o d 1955-1959 t h e r e w a s a 3% s u r v i v a l rate; by 1960-1964

t h i s had r i s e n t o 8%: and by 1965-1969 t h e s u r v i v a l rate had

i n c r e a s e d t o 16% (Sutow, V i e t t i & F e r n b a c h , 1977). Today 95%

o+ c h i l d r e n at d i a g n o s i s r e s p o n d to t h e i n i t i a l d r u q t r e a t m e n t

There are several intarnational graupz a+ pedxatric

oncologists !e.g.. the Children's Cancer Studv Group: CCSG)

who are responsible +or developing and re#ining the multimodal

treatment protocals. Patient assignment ta a particular

urotocol is determined Sv criteria such as t h ~ type o#

leukemia, the n~imker US white cells, platelets, the morpholaqy

of t h e cells and the age and sex oS the patient.

Management treatment includes chemotherapy, and may

inciude radiation therapy. Furthermore ths CCSG protocols

require that every three months (+mr +he high-risk group), ar

Sour months (fur the moderate-risk group). or six months [for

the low-risk group) the patient will underga a Ecne Marrow

dspiratiun !BMAZ and Lumbar Puncture <LPj to determine the

status o-F the di=.ease. This occurs an a routine basis when the

child is in remission and continues in most cases.for +ive

years when the child is then deemed disease-free.

The Bonn, Marrnw fispiraticlin ~rocedttr~?

A BMA is performed to obtain a liquid portion o+

marrow from the hip bone. Procedures vary across hospitals and

the fallowing description details the procedure in the surgery

roam of British Columbia Children's Hospithl, the setting of

the present study. The child usually lies on his or her

6

stomach over a pillow, which elevates the hip area. A local

anesthetic 04 Xylocaine 1 5 given by 'Jet', {This is a cylinder

that ~ j e ~ t s a small amount oS Xyl~carne under pr~ssure,

thereby simultaneously breaking the surface of the skin and

anesthetizing it.) The physician then proceeds to anesthetize

4 - . -- the underlying L I Z ~ ~ ~ and pericstiun using a syringe with

appraximately 2 ci of Xylocaine. When the area is

anesthetized, a hollaw aspiration needle is inserted into the

site and is burrowed into the iliac cr~st. Since tho bone is

not anesthetized, the child mav fee l some pressure or pain at

this point. Once in the marrow regIan o-F the bone. a small

portion af marraw is aspirated through the needle into a

syringe. This creates a momentary vacuum which is commonly

experienced by the child-as a sharp pain. The blc?od .

technologist who is present f or tho prncedurc immediat~ly

examines the specimen: i+ it contains the required marrow

granules, the needle is removed from the child's back and a

band-aid a~plied. Once the local anesthetic has taken ef-fect,

the procedure can be per#ormed in a +ew minutes.

There are usually no physical side-e+fects from the

procedure apart from a tenderness once the anesthetic has worn

of+. The child is physically able to get up immediately and

return home. Very frequently however, the child has been

distressed by the pracedure and the sta4f encourage the child

to rest on a bed outside the surgery room.,

L~~F~nl,Behavieuz~-in_~[re~~crn~e~~~~E,HA,~

In general, children with ALL appear to fear the BMA

7

more than any ather procedure. Katz, Kellerman Fii Siegal (1980)

noted that anxiety in response to EMAs was "virtuallv

ubiquitous" in their sample of 113 children, and that the

children did not habituate t~ repeated pracedures. In some

r3ses a ~lassically-conditioned anticipatory response pattern

cccurred, and anxiety was elicited by the presentation of any

number of cues associated with the pain+ ul event (Kellerman,

Zeltzer, Ellenberg, 8 Dash, 19833. Younger children tended to

display more avert anxiety than older children, who showed

their tension through muscular rigidity (Katz et al., 19803.

The medical staff at B.C. Children's Hospital and

parents reported the following manifestations o+ children's

anticipatory distress. On arrival at the hospital some

children refused to leave the car and actively fought with

their parents. It was not uncommon for children of all ages to

be pale, somewhat withdrawn and uncommunicative. clinging to

their parents in the waiting room. S o m ~ children resisted

entering the surgery room, bargaining with the nurse or - pleading the need to go to the bathroom; others entered

anxious and tense, holding a favourite toy, or parent's hand.

The child who came into the room without some overt display of

anxiety was the exception, and invariably was older than six

years.

During the BMA non-cooperative behaviours were

sometimes displayed, such as lying on the back and refusing to

turn onto the stomach. Delaying tactics such as asking

questions about the equipment and the procedure in an attempt

8

t o f o r e s t a l l t h e o n s e t commonly o c c u r r e d . S t a f f answered t h e s e

q u e s t i o n s b r i e + l y . I f t h e c h i l d became a g i t a t e d and began

k i c k i n g , t h e n u r s e s used p h y s i c a l r e s t r a i n t t o h o l d t h e c h i l d

i n p o s i t i o n . P h y s i c a l r e s t r a i n t w a s m o s t commonlv used w i t h

c h i l d r e n under s i x y e a r s of age . Some c h i l d r e n l a y p a s s i v e l y

ar cried soSt?v. Other c h i l d r e n w e r e c o m p l i a n t a n c e the

p r o c e d u r e began b u t remained h y p e r v i g i l a n t and immedi atel y

screamed t o any p a i n s t i m u l u s . I t w a s c l e a r l y a p a i n f u l as

w e l l a s a n x i e t y p rovok ing p r o c e d u r e f o r a l l c h i l d r e n .

The Lumbar P u n c t u r e Procedurg

T h i s p r o c e d u r e , also known a s t h e s p i n a l t a p , is

g e n e r a l l y e x p e r i e n c e d as less p a i n f u l t h a n t h e FMA. I t d o e s

however, t a k e l o n g e r and t h e c h i l d h a s t o b e c a r e f u l l y

p o s i t i o n e d i n a f e t a l - l i k e p o s i t i o n s o t h a t t h e s p i n a l

v e r t e b r a e are exposed. Once a g a i n t h e local a n e s t h e t i c , t h e

Jet, is a p p l i e d t o t h e s k i n area between t w o v e r t e b r a e .

F r e q u e n t l y t h i s is f o l l o w e d by f u r t h e r local a n e s t h e t i c g i v e n

by s y r i n g e so t h a t when a f ine -gauge n e e d l e is i n s e r t e d i n t o

t h e e p i d u r a l s p a c e between t h e v e r t e b r a e minimal d i s c o m f o r t is

e x p e r i e n c e d . A sample of c e r e b r a s p i n a l f l u i d is d r a i n e d o f f ,

and t h i s c a n t a k e a number of m i n u t e s depending on t h e f l o w of

t h e + l u i d . I t is i m p o r t a n t d u r i n g t h i s p h a s e t h a t t h e c h i l d

r e m a i n s m o t i o n l e s s i n t h e c u r l e d p o s i t i o n , as t h e n e e d l e is i n

h i s or h e r back and movement c o u l d d i s l o d g e i t c a u s i n g i n j u r y

and p a i n . I f t h e c h i l d r e m a i n s still, no p a i n is e x p e r i e n c e d

o n c e t h e l o c a l a n e s t h e t i c is comple ted and t h e s p i n a l n e e d l e

i n p l a c e .

9

Both prophylactically and in cases where the l ymphoblasts have

in#iltrated into the central nervous system treatment, drugs

are injected into the cerebrospinal fluld. Thlzi occurs a9ter

the fluid-tap, with the LP needle still in psziitian. It is a

painless pruredure. Once completed, the needle is removed and

a band-aid applied. There are usually no side-e-f-fects from the

LP a5 long a5 the child lies horizontally and rests +or

approximately an hour a#ter the procedure. If the child is

immediately active he or she may experience a headache,

because of changes in the cerebrospinal fluid. After the rest

the child may play, return to school or go home.

I ~ e L ~ a l - B e h a v i n ~ r s - L n ~ B s ~ e o ~ ~ s e ~ t o ~ I ~ s

Since the LP is frequently given following the BMA, it

is difficult ta discern prior to the procedures which

behaviours were specific to the LP. From parent's and

clinician's reports, children are less fearful of the LB as it

is seemingly less pain#ui. The younger child's major

difficulty was curling into the -Fetal-like position and

remaining motionless for up to ten minutes.. Concern for

correct placement at critical periods resulted in the younger

child being held by the nurse, which frequently provoked the

child's rage and anger. Sometimes further bargaining

interactions between nurse and child occurred, for example,

"If. you keep very stiil, I won't need to hold you..otherwise

I'll have to hold you, and you don't like that!"

~ e d i c a l S t a f f Burn-out

& p a r t f r o m h i n d e r , i n g t h e p r o c e d u r e , t h e c h i l d ' s

d i s t r e s s is a l so a s o u r c e oQ stress a n d d i s c a m + o r t f o r t h e

m e d i c a l s t a f f . Koocher (19801 i n h i s e x a m i n a t i o n o f t h e " h i g h

cast QS h e l p i n g " i n t h e p e d i a t r i c o n c o l c g y u n i t , n a t e d t h a t

t h e stressars are i n t e n s e . Anger , g u i l t , f r u s t r a t i o n a n d

e m o t i o n a l burn-out f r e q u e n t 1 y accompany a s e n s e of

h e l p l e s s n e s s i n t h e c a r e t a k e r s of c h i l d r e n w i t h c a n c e r .

E e c a u s r o+ t h e s e combined +actors Koocher n o t e d t h a t t h e

p e d i a t r i c a n c o l o g y 5 ta f - f is p a r t i c u l a r l y s u s c e p t i b l e to

' burn-out ' . Concern +or o n c o l a g y n u r s e burn-out is

s u b s t a n t i a t e d by a number o f a r t ic les i n n u r s i n g j o u r n a l s

d e v o t e d t o t h i s p rob lem < e . g . , McElroy, 1982; Newlin &

W e l l i s c h , 1978; Ogle , 1983).

cai n: C o n c e p t u a l F ' r o b l ~ m ~

P a i n is a complex phenomenon. It p r e s e n t s n u m e r ~ u s

c o n c e p t u a l , e x p e r i m e n t a l a n d p r a c t i c a l m y s t e r i e s f o r b o t h

r e s e a r c h e r a n d c l i n i c i a n . Over t h e l as t t h r e e d e c a d e s i t h a 5

become i n c r e a s i n q l y clear t h a t p a i n r e s p o n s e s c a n b e a + f e c t e d

by p s y c h o l o g i c a l v a r i a b l e s o - f t en t o a much g r e a t e r d e g r e e t h a n

by p h a r m a c o l a g i c a l means (Wei senbe rg , 1977). T h i s h a s l e d many

r e s e a r c h e r s t o r e g a r d p a i n as d e t e r m i n e d i n p a r t b y

p s y c h o l o g i c a l f a c t o r s which are u n r e l a t e d t o t r a u m a or

d i s e a s e . I n c o n t r a s t t o c h r o n i c p a i n , which t e n d s t o b e

a s s o c i a t e d w i t h l o n g s t a n d i n g p e r s o n a l i t y p rob lems . a c u t e p a i n

is g r e a t l y i n f l u e n c e d b y t h e a n x i e t y o f t h e p a t i e n t a n d r a r e l y

11

exists. in the absence a+ any emotion <Chapman,l?77)g

To add to the complex understanding af pain. same

researchers (egg., Beecher, 194.5; Chapman, 1977) emphasize

that +ram the observer's perspective the emationdl aspect of

the pain experience cannot be meaning+uiiy separated +ram the

sensary input. There is cansensus that pain cannot be

construed as unidimen~ional and 1s best described as a

m u 1 ti dimensional phenomenon, which includes naxlaus sensory

input, a motivational-emotlanal drmenslan. a

conc~ptual- judgemental dimensl on and a sac1 al -cul tural

dimension (Chapman, I???). There 1 5 a dynamic

interrelatronshlp among the three behavioural dlmenslans 50

that a shift in one madifles the other, resulting in a change

in the processing and experience of the noxious sensarv ~npui.

Fain in Children with Leukemia

For the child with leukemia, pain is a +resuently

encountered experience, yet there is a general belie+ that

pain is less problematic for children with cancer than adults.

The belief reflects more a neglect of the subject of pain in

children in general, than a full understanding of pain in

childhood cancer (Beales,l9?9). For some patients the disease

in the beginning and middle stages may be substantially

painless, apart from the acute pain experiences during the

panoply of intravenous injections, bloodtests, BMAs and LPs.

However for many other children, pain emerges as a central and

distressing feature of the disease.

12

The Role of Psyrhologicai Interventian -----c-------- ----- -----------------

Assessment of Chi l dhcmd f'ai n and Su-i f eri nq

Traditional i y p5ychoiogists have provided emotional

support, and individual and family therapy for children in

pain. Psychoiogical theories and meth~ds also have something

o+ value ta aSfer in the realm af objective ass,zssment and

clinical management o-f pediatric pain and anxiety. Researchers

(Jay, Ozolins, Elliott, % Caldwell, 1983: Katz, Kellerman &

Siegal , 1980: Legaron & Zel tzer, 1982) have recent1 y developed

assessment measures for the neglected area w+ peaiatrlc

oncology distress. These instruments are situation-specific

and designed for t h e pedi.atric population.

Since parents and medical staff tend to underestimate

the child's level of pain and suffering (Eland b Andersan,

19771, the use of subjective as well as objective measures is

advocated. A personal report is important information from a

group of patients that is generally i 11-equipped to eloquently

describe pain and distress. However, Johnson & Melamud 11979)

9ound that self-report measures for children under eight Years

were problematic. In t h e pilot stage of the present study, the

author developed two self-report scales, which addressed the

need for a validated and develapmentally accurate self-report

m~asure for children +rom four to ten years oS age. These

scale& will .be used in the present study.

13

p s y c h o l ~ g i c a l l y i n t a c t , t h e young c a n c e r p a t i e n t and f a m i l y

h a v e t o a d j u s t t o t h e r e g u l a r h o s p i t a l v i s i t s and r e c u r r e n t

EM& and LPs . T h e r e is an overwhelming need f o r p s y c h o l o g i c a l

i n t e r v e n t i o n s t o e n h a n c e c o p i n g s k i l l s d u r i n g t h e t r a u m a t i c

and + e a r e d EM& and LP. Case s t u d i e s s u g g e s t i n g t h e

e f f e c t i v e n e s s o+ h y p n o s i s (Gardner , IF?&; O l n e s s , 1981 i are

among t h e earlier r e p a r t s d e t a i l i n g p s y c h o l o g i c a l

i n t e r v e n t i o n s f o r c h i l d h o o d p a i n . Hypnos i s a p p e a r s t o h a v e

remained o n e of t h e m o s t f r e q u e n t l y r e p o r t e d i n t e r v e n t i o n +or

a c u t e p a i n and a n x i e t y i n p e d i a t r i c c a n c e r p a t i e n t s CGardner %

O l n e s s , 1981). The + e w s y s t e m a t i c a l l y c o n t r o l l e d s t u d i e s a f

hyp t tos i s w i t h a d o l e s c e n t s and c h i l d r e n aged s i x y e a r s and .

a l d e r have r e p o r t e d p r o m i s i n g r e s u l t s f o r managing p a i n and

a n x i e t y . ( H i l g a r d & LeBaron, 1982; K e l l e rman, Z e l t z e r ,

E l l e n b e r g 24 Dash, 1983; Z e l t z e r b LeBaron, 1982). The s t u d i e s

w i l l b e r ev iewed i n d e t a i l i n c h a p t e r t w o .

E e h a v i o u r a l methods h a v e emerged as a v i a b l e

a1 t e r n a t i v e t e c h n i q u e f o r t h e management of p a i n and a n x i e t y

( J a y 2% E l l i o t t , i n p r e s s ) . P e r h a p s t h e o l d e s t of t h e s e methods

is t h e t e c h n i q u e of d i s t r a c t i o n . Ev idence shows t h a t t h e

mechanisms of a t t e n t i o n and d i s t r a c t i o n p a r t i c u l a r l y z n f l u e n c e

t h e s e n s a t i o n component o f p a i n (Melzack, 1973). - A t t e n t i o n

i n c r e a s e s t h e a b i l i t y t o d e t e c t t h e s e n s o r y s i q n a l s , and

\

c o n v e r s e l y , d i s t r a c t i o n s h i f t s a t t e n t i c m so t h a t a s t r o n g e r

s i g n a l is r e q u i r e d t o p r o d u c e a d e t e c t a b l e s e n s o r y s i g n a l .

The e f f i c a c y o f d i s t r a c t i o n as a t r e a t m e n t m o d a l i t y f o r

c h i l d r e n (from A y e a r s o l d ) and a d o l e s c e n t s w i t h p a i n , h a s

been s p e c i f i c a l l y i n v e s t i g a t e d i n o n l y o n e s t u d y { Z e l t z e r &

1 4

LeBaron, 1992). This is surprising, although there are many

references tu distraction as a treatment method le.q., Alcock,

Berthiaume & Clarke, 1984; Savedra, 19761. The reports suggest

that the method has merit, and an the basis oS this one may

hypothesize that distraction will also b e helpful to the

ynunger child ( 3 to 6 years), the age graup that f a r m s the

highest percentage of ALL suf9erers.

15

CHAPTER TWO

REVIEW O F THE LITERUTURE

Definitions and Concepts of i?s:in_

Since earliest times, humanity has pandered and

struggled to make sense of the puzzle o+ pain. To the ancient

Greeks, pain was an emotion: Aristotle described pain a s a

quality of the soul and the epitome of the feeling of

"unpleasantness", and did not intrinsically consider pain as a

sensation. These early conceptions recoqnired that pain may

come from many sources in the outside world and may be

experienced a5 unpleasantness within the body and the 'soul'

when one is miserable (Hardy, Wolff S Goodell. 1952).

In the intervening 'centuries, the notxon ot pain a s

unpleasantness (the experience of discomf ort and something t o

be avoided) lost sway and merqed with the notion o+ paln a s

sensation (Boring, 1952). The concept of pain altered again in

the mid 18OOs during the development of sensory physioloqy and

psychophvsics by Weber, Helmholtz and Wundt, among others.

Pain achieved a new status in 18&4 when Von Frey mapped out

separate pain and pressure spots on the human body and thereby

establ ished that pain was a sensation with distinctive

qualities and different from the emotion of unpleasantness

(Hardy, Wolff & Goodell, 1952). -

The problems and complexities in understanding paln are

also reflected in the varied contemporary definitions of pain.

The most frequently quoted de+inition of pain in nursing

journals is "Pain is whatever the experiencing person says it

is, existing whenever he says it does" (McCaf fery, 19721. Among

health proiessionals the nurse roba ably has the most Sreouent

rantart with people in pain. The definitian quoted above

reflecis a pragmatic management attitude t~wards pain. It

gives absolute credence to self-report gf the -~.i_!ffrrer, and

thereby avoi ds any epi sternal oqical prabf emz..

In the psychological literature, .ane o f t h e m o - z i t

oft-quoted definitisns of pain is that afiered by Sternbach

<l968). He describes pain as

an abstract concept that reiers %a i l l a prrsonal, private sensation o# hurt; (2) a harmful stimulus t h a t s i g n a l s current ar impending tissue damage; ( 3 ) a pattern a+ responses which operate to protect the organism Srom harm (p. 1 2 ) .

This definition includes a subjective sensakian

component and deals with -the neurophysiof ~ q l c a l a-soects rn

terms of stimulus-response. It does nat clearlv articulate the

sufferer's construal of pain. Pain reactions ireq~rent1.v rcfivey

a great deal more than a signal that tissue damaqe is

occurring. For example, the same pain s.timi-tlu5 can be

experienced and expressed in dramatically difSerent w a y s by

different individuals.

An adequate definition of pain must therefore include a

cognitive component-that recognizes the varying meanings af

pain for the individual. The meaning will be determined in

part by the individual's past experiences and associations'and

the ability to understand the cause and consequences of the

pain (Turk, 1978). Precisely how a def inition will accatint for

the interaction between the components remains a problem since

"the relative contributions of sensory stimulation, emcttions

a n d c o g n i t i o n s t o t h e e x p e r i e n c e o9 p a i n r e m a i n u n r e s a i v e d ,

and c o n t i n u e t o b e a c e n t e r of c a n t r o v e r s v among

t h e o r e t i r i a n s " (Turk , 1378, p.200i.

The Task F a r c e on Taxanomy a f t h e I n t e r n a t i a n a l

d e f i n i t i c n s f p a i n :

An u n p l e a s a n t s e n s o r y and e m o t i s n a l e x p e r i e n c e ars.oci st& w i t h a c t u a l or p o t e n t i a l t i s s u e damage, or d e s c r i b e d i n t e r m s of s u c h damaqe (IASP Subcommi t t ee on Taxonomy, 1979, p. 250) .

T h i s d e f i n i t i o n c o n v e y s a m u l t i d i m e n s i o n a l p e r s p e c t ~ v

a n d t a k e s i n t a a c c o u n t t h e s u b j e c t i v e n a t u r e o+ p a i n . T h i s 1 5

t h e u n d e r s t a n d i n g s f p a i n t h a t w i l l b e u s e d i n t h e p r e s e n t

s t u d y .

T h n o r F e s of P a i n and Suf f e r i n q

E a r l y 2 0 t h c e n t u r y t h e o r i e s o f p a i n a n d s u f f e r i n g w e r e

b a s e d on s t i m u l u s - r e s p a n s e models . P a i n p e r c e p t i o n w a s

r e g a r d e d a5 a d i r e c t f u n c t i o n of n e u r a l s t i m u l a t i o n i n i t i a t e d

b y damage or i n s u l t t o t h e t i s s u e . T h e r e w a s t h e r e f o r e a

p r o p o r t i o n a l r e l a t i o n s h i p o f i n t e n s i t y be tween t h e s i z e of

n e r v e e n d i n g s t h a t w e r e n o x i o u s l y s t i m u l a t e d , and t h e -

m a g n i t u d e of p a i n e x p e r i e n c e d .

Wi th in t h i s n e u r o p h y s i o l o g i c a l l y b a s e d model , t h e r e are

t h r e e c u r r e n t t h e o r i e s : t h e s p e c i f i c i t y t h e o r y , t h e p a t t e r n

t h e o r y and t h e g a t e - c o n t r o l t h e o r y of p a l n . A s t h e name

s p e c i f i c i t y s u g g e s t s , t h e s p e c i f i c i t y t h e o r y p r o p o s e s a

s p e c i f i c set o f p e r i p h e r a l n e r v e + i b r e s known a5 A-de l t a and C

f i b r e s , t h a t are p a i n r e c e p t o r s . I n c o n t r a s t , t h e p a t t e r n

t h e o r y p r o p o s e s t h a t p a i n is t h e r e s u l t a n t summat ion uf

s p a t i a l and t e m p ~ r a l p a t t e r n s of i n p u t : p a i n p e r c e p t i o n is

t h e n b a s e d on s t i m u l u s i n t e n s i t y and c e n t r a l summat ion , and

t h e r e a r e nn 5 p e c i S i c p a i n r e c e p t o r s i n the p e r i p h e r a l n e r v o u s

Running c o u n t e r t ~ , and m e r e ~ n S l u e n t i a l t h a n t h e a 5 c v e

t w o t h e o r i e s is t h e g a t e - c o n t r o i t h e o r y o+ p a i n . d e v e l o p e d b y

Melzack and Wall (19651. I t p r o p o s e s t h e f o l l a w i n q :

N e u r a l mechanisms i n t h e d a r s a i h o r n s of t h e s p i n a l c o r d act l i k e a g a t e which c a n i n c r e a s e o r d e c r e a s e t h e + l a w a+ n e r v e i m p u l s e s f r o m p e r i p h e r a l i i b r e s t a t h e spinal card ce l l s t h a t p r o j e c t ta t h e b r a i n . S o m a t i c i n p u t is t h e r e f o r 2 s u b j e c t e d t o t h e m o d u l a t i n g i n f l u e n c e o+ t h e gate b e f o r e it e v e k e s p a i n p e r c e p t i a n and r e s p o n s e . The t h e o r y s u g g e s t s t h a t . . . t h e g a t e is p r o f o u n d l y i n f l u e n c e d by d e s c e n d i n g i n f l u e n c e s f r o m t h e b r a i n i t l e l z a c k % D e n n i s , 1978. p . 2 ) .

W i t h i n t h e g a t e - c o n t r o i t h e o r y a one- to-one r e l a t i o n s h i p

be tween s t i m u l u s and p a i n i n t e n s i t y is n o t h y p o t h e s i z e d . The

p e r c e p t i o n of - p a i n is n o t t r a n s m i t t e d d i r e c t l y f r o m s k i n

r e c e p t o r s t o t h e b r a i n 7 s p a i n c e n t r e ; i n s t e a d s e n s o r y

i n f o r m a t i o n is s e l e c t e d a t v a r i o u s l e v e l s o f the c e n t r a l

s y s t e m . Most i r n p o r t a n t l v , t h e b r a l n c u n t r o l s and i n f l u e n c e

t h i s p r o c e s s .

The g a t e - c o n t r o l t h e o r y is u n l s u e f o r its c o m p r e h e n s ~ v e ,

e l a b o r a t i o n of n e u r o p h v s i a l o g i c a l mechanisms o-f p a i n s e n s a k i a n

a n d its p r o p o s e d c o g n i t i v e - r n o t ~ v a t ~ u n a l c ~ r n p a n e n t s t h a t

a c c o u n t f o r a v o i d a n c e o+ p a i n CWelsenberg, 19772. B y i n c l u d i n g

c o g n i t i v e p r o c e s s e s t h a t c o n t r o l o p e n i n g or c l o s i n g t h e

" g a t e " , t h e t h e o r y a t t e m p t s t o a c c o u n t f o r t h e v a r i a b i l i t y .

be tween a p a i n f u l s , t i m u l u s and p a i n peS-kep t ion or r e s p o n s e . ,

However, as Weisenbe rg 119771 n o t e s , t h e t h e o r i s t s h a v e n o t as

19

yet clarified the exact mechanism involved in gate cantrol.

. , Despite this shortcoming its importance remains, sinre :r

I1 . ries together many a+ the puzziing aspects a+ pain perception

and control..Eandl has had a pra+ound in+iuence on pain

research and the clinical control of pain" (p.lO12i.

Clinically, one c+ the heipSul distinctions in pain

diagnosis and treatment is the differentiation o i pain states

into acute and chronic.

Bsuke-anLGksnLc-EaIn

Acute pain occurs in a traumatic event or disease

(Chapman, 1977). A s a sensation, it is most commonly felt as a

sharp impelling noxious stimulus, and consequently

infrequently exists in the absence of emotions such a5

anxiety, fear or anger. Acute pain usually subsides with the

progression o+ the healing process. It theredore serves an

adaptive function as a signal of damage or organ pathdogy

that ran prompt medical attention. The accompanying +ear

component during acute p a n also dist~nguiches ~t Srom chrnnlc

pain. Chronic pain, in contrast is well-established,

frequently recurring or constantlr present over a number of

months. Importantly, chronic pain has proved to be refractory

to conventional medical treatment <Chapman, 1977).

The psychological treatment models for these two pain

conditions can di-F-Fer. Since pain caused by EMAs and L P s is

acute, the review of the literature for this study will

examine research on acute pain and suffering only.

Furthermore, since these procedures are invasive, a particular

20

emphasis will be given to treatment outcome studies of

invasive medical and dental procedures,. First adult studies

wi 11 be reviewed, because hi storirai 1 y adult sutcome research

has tended to precede that relating to children. A critical

e:-:ami nati on of the a d d t studies wi l l provide an apportkmi ty

ta explore and expand upon the diSSerent theoretical

underpinnings. Child treatment outcome studies will fa1 low and

I ssue~. the focus will be on both treatment and methodological 1

The classic study describing the subjective meaning and

multi-dimensional nature of pain was recorded by the World War

If surgeon, Beecher (1946). The prevailing stimulus-response

model of the day led naturally to a reliance an medication or

surgery to reduce pain. Beecher (1946) questioned the adequacy

of the model.

There is a common belief that wounds are ~nevltablv associated with pain, and further, that the more extensive the wound, the worse the pain. Observations of freshly wounded men in the Combat Zone showed this generalization to be misleading. If one may speak of such a subjective experience as pain in exact terms, the generalization can be said to hold in only about one-quarter a+ severe1 y wounded men; it fails in the remaining three-quarters (Eeecher, 1946, p.96).

Beecher noted the significant discrepancies between pain

responses of soldiers wounded on the battlefield, where a

wound meant a ticket home or to safety, and civilians who

sustained similar in juries and displayed significantly more

suffering. He emphasized that from the perspective of the

physician, the emotional component o+ pain cannot be

meaningful ly separated from the sensory stimul i . His

21

o b s e r v a t i o n s of t h e a p p a r e n t s i t u a t i o n a l i n d e p e n d e n c e be tween

t i s s u e damage a n d t h e s u b j e c t i v e r e p o r t o f p a i n , led t t l r a

w i d e r a c c e p t a n c e o+ t h e i d e a t h a t p s y c h o l o g i c a l +ac tors p l a y

a n i m p o r t a n t a n d f r e q u e n t l y m e d i a t i n g ro le i n the p e r c e p t i o n

and management o+ p a i n .

I n a n o t h e r i m p o r t a n t e a r l y r e p o r t Wolff and Goode l l

C19431 s t u d i e d t h e r e l a t i o n o f p s y c h o l o g i c a l and s x t u a t i m a l

f a c t o r s t o t h e p e r c e p t i o n and r e a c t i o n of p a i n , They

q u e s t i m e d t h e n o t i o n t h a t t h e p a i n t h r e s h o l d r e m a i n e d ~ i n i f r l r m

r e g a r d l e s s of mood, e f f e c t i v e n e s s , s l e e p i n e s s or f a t i g u e .

Wolf+ a n d Goode l l w i shed t o draw a t t e n t i o n t o t h e f a c t that

" t h e r e a c t i o n t o p a i n may b e d i s s o c i a t e d + r a m p a i n I n many

ways" (p .4451, a n d b y m a n i p u l a t i n g p s y c h o i o g i c a l a n d

s i t u a t i o n a l f ac tors , t h e v s u b j e c t ' s r e p o r t s on t h e p a l n

t h r e s h o l d c o u l d b e r a i s e d or lowered . They e x p o s e d s ~ t b j e c t s t o

d i + f e r e n t f a r m s of d i s t r a c t i o n , a u t o - s u g g e s t i o n and h y p n o s i s ,

w h i l e f ~ c u s 5 i n g h e a t f r o m a 1OOO w a t t electric b u l b on t h e i r

f o r e h e a d s , which had b e e n b l a c k e n e d . Us ing an u n d i s c l o s e d

number b u t e v i d e n t l y s m a l l g r o u p of s u b j e c t s , Wolff a n d

G o o d e l l e s t a b l i s h e d t h e p a i n t h r e s h o l d f o r t h e s u b j e c t s , t h e n

v a r i e d m e d i c a t i o n , p l a c e b o , t h r e e f o r m s of d i s t r a c t i o n ,

a u t o - s u g g e s t i o n and l i g h t h y p n o s i s . The r e s u l t s d u r ane of

t h e i r s u b j e c t s w e r e as f o l l o w s :

1. Stories of a h i q h l y a d v e n t u r o u s n a t u r e t h a t w e r e r e a d

a l o u d , r a i s e d t h e p a i n t h r e s h o l d b y a b o u t 16%

2. A u t o s u g g e s t i o n s s u c h as, " I won ' t f e e l p a i n " r a i s e d t h e

t h r e s h o l d b y 20%

3. A l o u d l y c l a n g i n g b e l l r a i s e d t h e p a i n t h r e s h o l d by 38%

4. A light hypnotic trance raised the pain threshald by 40%

5. The retention and r~petition of five to nine digits

forwards, and then backwards, raised the pain thresh~ld by

In a second series a+ studies Wolff and Gocdell examiged

the efSect5 of placebos and analgesics on pain threshald when

instructi~ns and suggestians to the subjects were varied. They

found that the effectiveness of analgesics was markedly

influenced by the attitude engendered in the subject. "Uaubts.

lack of ronf idence, relative alertness and increased

suggestibility with lethargy, were relevant..." fp.443) to the

reported pain thr~shoid, The acrthors concluded that their work

demonstrated that:

the pain threshold is- anything but uniform in man, if instructions are variable, and if #rill consideration is not given to such factors a5 attitude, maad, distraction, concentration, attention, lethargy and suggestibility (p.443). CThey added3 Ii the s~ibject despite his m ~ o d and letharqy, maintains a detached 'unprejudiced' objective attitl-tde towards the stimulus and if not exposed to suggestive words and procedures, then mood and lethargy have no e#fect on the level of pain threshold. But, if the subject during anxiety, tension, doubt or lethargy or during a suggestible state is in a situation which distracts from attention or fosters a conviction, then the pain threshold may,be altered (p. 444).

The Wolff and Goodell study, undertaken during the war

years, can be methodologically faulted in light of the

sophistication gained over the last forty years o-f scienti+ic

research. Nevertheless it remains of historic importance in

drawing scientific attention to the influence of psychological

and situational factors in mediating the experience o# pain.

,

23

Gnsn~tive,Beerssche~-ko~F;:ed~!~hn_~~F'_aL~!

Ad~tl t Studi es

During the 1950s, it was recognized that psychological

factors such a5 fear oC the unknown, anxiety about body damage

and apprehensions about pain and discom+ort may be aliev~ated

throttgh adsquate psychological p r s ~ a r a t ~ o n prxor to medr cal ,

dental ar surgical procedures. One o+ the earl zest forms a+

psychological preparation was the provision af accurate

information. Janis (1958) studied what he termed the "work a+ worrying". He +ound that a moderate level of preoperative fear

was the optimum level for postoperative adjustment. The

relationship between preoperative fear and postoperative

adjustment was curvilinear. Patients with either high or low

levels o+ preoperative fear seemed more likely to manifest

postcperative adjustment prablems. He hypothesized that only the

moderate level of preoperative fear was adaptive, as it

motivated the patient to begin the "work o# wa-rylng". This

invariably consisted o+ mentally rehearsing the event and

developing accurate expectations, which would result In the

mobilization of coping techniques.

A1 though Jani s' s evidence was methodologically weak, belng

based on retrospective reports and descriptive data from

nanrandom and limited samples, his theory intrigued researchers

and a spate of studies followed which attempted to verify the

curvilinear relationship between anticipatory anxiety and

subsequent recovery. Anderson and Masur I l?83) reviewed this

literature and concluded that, in general, patients receiving

detai 1 ed procedural information about a medical or dental

invasive event and it% aftermath have scored only slightly

better than controls on indices of recoverv. The pvsltive

zorrelatian between outcome and anxiety 1evrPs war upheld and it

has lent further credibility to the continued development of

anxiety-reducing techniques #or medical, dental and surgical

procedures.

Investigators turned to an examinatinn a+ diSf erent types

of inf ormati on. The most ef i i caci or-15 ir a combinati on of sensory

and procedural details fe.g,, "When the dye is injected

(procedural), you will feel a hot flash"(sensory)l. Johnson b

Rice (1974) studied the amount and type of sensory in+armation

effective in reducing the distress and the pain intensity

experienced during laboratory induced ischemic pain. They

hypothesized that the amount of distress and intensity of pain

would be a function of the congruence between expected and

experienced physical sensations. Subjects were provided with one

of the f 01 iowinq conditions: a description a+ sensations

unlikely to occur; a dezcription of onfv two sensations that the

subject might expect to experience: a descript~on o+ all the

typical sensations; and a description void of sensations.

Information that described two commonly experienced sensations

was found to be as effective in reducing distress as was

information that fully described the sensation.

In summary, findings in the adult studies suggest that

procedural and sensory in+ ormation alone can have beneficial

effects on psychological outcome. The critical ingredients as

well as the rationale for this, still require further

clarification.

Chgldren's Stitdi e ~ :

Fallowing the adult research, it w a s assumed thst children

would also benefit -from inf ormatian about hospi tal and medical

procedures. Research in this area evolved +ram studies of

children's reactions to hospitalizatian le.g., Priigh, Staitb,

Sands, Kirschbaum % Leniban, 14521, Frequent reactians observed

were anxiety about painful procedures, as well as distress at

un+amiliar surroundings and separation +ram parents. Pracedural

indormation which reduces children's stress has generally taken

the form af hospital tours. puppet plays and preprocedural

teaching. Providing in+ormation has become relatively

commonplace in pediatric hospitals and clinics. A r-ecent survey

reported that 70% of non-chronic care pediatric hospitals

provided some +arm o# preparation iPeters~n Hidlev-Johnson,

19801. Melamud, Hobbins & Graves (19821 expressed caution in the

general implementation of these programs. "The lack of careSul

evaluation of the methods being used results in confusion as to

which approaches are appropriate for which yaungster-s"{p. 22b).

Age and developmental considerations are basic to valid

child research. If information is to be used as preparation #or

children undergoing medical treatment, a number of questions

need to be addressed, such as: what infarmatian is

developmentally appropriate for children of different ages; how

is the information presented: when is the optimum time for- the

presentation; should parents be included in the preparation; how

would pre3ious experience in that situation modify these

considerations: and should the treatment effects be evaluated.

26

Some o+ these questions were addressed in the following studies.

The a~.~umptian that all children can benefit from information

abmtt upcoming hospital procedures, has been disputed ( M e 1 amud,

Oearborn % Hermecz, 1983: Melamud, Gee % Soule, 19761. Melamud

et al., (1976) reported that children under seven yEars od age

who are prepared too far in advance become sens~tized and

demonstrate more anxiety about the forthcoming procedure.

He-examining this issue, Melamud et a1.(1983), investiqated the

ef+ects of age. previous hospital experience and type of

in+m-mat~un provided (hospi tal-relevant or- irrelevant film) . Results supported the effectiveness of hospital -re1 evant

information +sr improving the experience and recaverv +ram

surgery for children above eight years of aqe. However, children

under eight years with previous surgical experience reported

increased medical concerns if they vlewed the hcspital-relevant

presentation, Interestingly, when shown the hospital-irrelevant

film, these experienced yuunger children tended to shuw

decreases in anticipatory concerns. It may be that the children

had been distracted from the impending procedure by the

irrelevent material. This potentially supports the use of a

distracting film as an anxiety-reducer for surgically

e:.:perienced chi1 dren under eight years. Melamud et. dl. c a u t i ~ n

that young but hospital-experienced children are the most

vulnerable to the ef-Fects of medical stress. Consequently the

authors recommended that future research evaluate the type of

preparation and coping instructions that would be use+ul to this

vulnerable group. . Petersan % Siegal (1981) decided to examine treatment

27

techniques that were less age-bound and more cost-e-ffective than

video-taping. They compared the effects of sensarv information

. with the effects of coping skills frelaxation and coping

instructions) on preschaol children's responses to repeated

dental procedures. There were no diSber-ences in e-ffectiveness

betwsen sensory in-Formatian and coping techniques. The

eiiectiveness o-f the prepar-atian was maintained during a second

dental treatment a week later. In an earlier study, Siegal and

F'ekersan (1980) had found that only a brief intervention was

necessary to attain significant eidects for these techniques at

initial visit.

Jn summary, studies on dental and surgery in+ormation +or

children indicated that age and developmental considerations are

central for successful preparation. Studies investigating the

effects of madelling indicated that children aged eight and

older, fared best with relevant in+ ormation. Children under

eight, who were prepared for the procedures prior to a week

be-fore the event, become sensitized and demonstrated

considerable anxiety. Particularly vulnerable were the children

under eight years who had previous surgical procedures. Unlike

children above eight years of age, this group evidenced

anticipatory anxiety when shown material relevant to their

impending procedure. Providing them with distracting irrelevant

material reduced their anxiety. For dental procedures b r l e f

intervention for pre-school children of sensory information or

coping instructions prior to the initial visit reduced anxletv

and distruptive behaviours. This preparation was maintained on

the second visit.

,

28

Information as the sole psychological intervention for the

more stressSul procedures such as BMAs and LPs has limited

beneSits. In-Farmati~n is a ? ~ e a k competitor with pain and the

high level of anxiety induced by these invaslve surgical

proredur~s. Moreover, sinre the procedures are repeated the

children beccme "experienced" and Srequentfv become more upset

in anticipstion of the event. Information is most frequently

given prior to the procedure, and may have limited therapeut~c

value during the painful event. Therapeutic intervsntian +or the

more painful procedure may need to be more active (Zeltrer Z-:

LeEaron, 19541, occurring immediate1 y prior ta, and having

continuity throughout the duration of the procedure.

Modelling as observational learning has also been used as

a pre-procedure techniq~te. Studies indicate that model 1 ing is

mar= ef+ective than information-only with young children.

Nevertheless modelling suffers from the same deficiencies as

inbnrmation in not ensuring continuity of the coping skills

dut-ing painful medical pr-ocedures.

f ndividual Differences ...................... Even within the more painful procedures, individual

differences in styles of coping and information processing have

been noted (Hilgard $4 LeEaron, 1982: Jay et dl., 1982). Hhen

faced with threat, individuals may exhibit a wide range of

reactions. Common reactions are avoidance, vigilance or bath. In

coping with medical stress, the repressor-sensitizer dimension

stands out among other possible relevant individual di+ferences

in the literature.

29

Repressors for minimizers) are individuals who prefer t o

cope with strefs by svoiding or denylng the emotional or

threatening aspects of the ex~erience. Such indzvxduais show a

limited Cnswledge or awareness of the medzcal condition or

pi-acedure, and are unwilling t o discuss thoughts about the

p r c c e d v r ~ s (Cd-ien L Lararus, 1973, p. 3791. There 2s a cantinuurn

in this style ranging from total denial t o reasonable duuht

flipowski, 1970, p. 96).

Sensitizers (or the vigilant mode) are typified by their

attention to in+ormation about the stressors, and becoming

over1 y alert t o emotional a- threatening aspects of the upcctming

experience. Sctrh individuals actively seek knowledge abocti the

procedure and show a readiness t o discuss the experience iCohen

& Lararus, 1973, p. 379). This style too is viewed as a

cantinuurn ranging from beinq hypervigilant and exaggerating all

bodily threats, t o having a realistic recognition of the

threats, the tasks, and the need for rational planning

(Lipowski, 1970, p. 96).

Cohen & Lazarus (1973) provided the following examples tu

illustrate. the different styles. Repressor: "ki 1 I know is that

I have a hernia....I just took it for granted ... doesn't disturb

m e one bit....have no thoughts at all about it."

Sensitizer: " CAf ter a detailed description of the medical

procedure and the operation"^ procedurel...I have all the facts,

m y will is prepared.. ..it is major surgery.. .It's a body

opening.. .ymt're put out, you could be put out too deep, your

heart could quit, you can have shock....I go not in lightly."

Research with adults has demonstrated that these

30

i n d i v i d u a l c o p i n g p r s c e s s s e s a n d d i s p o s i t i o n s c a n i n f l l - i e n c e

r e c o v e r y Srom s u r g e r y iCoAen & i a z a r - u s , 1973). P a t i e n t s using

t h e r e p r e s s o r mode nf r a p i n g g e n e r a - l l y d i d best i n r e c a v e r y ,

w h e r e a s p a t i e n t s who u s e d t h e s e n s i t l z o t - mode showed a s l o w e r

cnc t r se o f r e c o v e r y , p a r t i ~ z i t l a r l y i n t e r m s o f number of d a y s i n

h c s p i t s ? and frequency of minor camp1 irations.

H a s p i t a l p r e p a r a t i o n w i t h adu? ts s u g g e s t e d t h a t i n d i v i d u a l

c o p i n g styles c o n t r i b u t e t o d i S S e r e n t i a 1 t h e r a p e u t i c e f f e c t s .

S h i p l e y , B u t t , H o r ~ i t z $4 F a b r y (1078! fcrund t h a t r e p r e s s o r s

showed a h e i g h t e n e d h e a r t rate d u r i n g e n d o s c o p i c i n s e r t i o n i f

t h e y had viewed a p r e - s e n t a t i a n o f a c o p i n g model v i d e o t a p e ;

w h e r e a s f o r s e n s i t i z e r s h e a r t r a t e w a s r e d u c e d . Ther-ef ore, it

coctld b e e x p e c t e d t h a t r e p r e s s o r s s h o u l d d o p a r t i c u l a r 1 y w e 1 1

w i t h d i s t r a c t i o n . T h i s wa; i n d e e d d e m a n s t r a t e d by H a r w i t z ,

S h i p l e y ZX M c G ~ t i r e (1977; c i t e d i n McCai11 ?< Malott, 19841. who

e x p o s e d r e p r e ~ . s o r - 5 and s e n s i t i z e r s t a e i t h e r d i s t r a c t i n g or

n o - t r e a t m e n t c o n d i t i o n s d u r i n g e n d o s c o p i c e x a m i n a t i o n . P h y s i c i a n

and n u r s e s r a t e d t h e p a t i e n t s and t h e e v i d e n c e i n d i c a t e d t h a t

r e p r e s s o r s i n t h e mus ic c o n d i t i o n had less d i s c o m f o r t when

compared t a t h e c o n t r o l c o n d i t i o n . The 5 e n s i t i z e r 5 however

m a n i f e s t e d t h e upposi t e e f f e c t , d i s p l a y i n g m o r e d i s c o m f a r t . This

s u g g e s t s a n i n t e r a c t i o n e f f e c t be tween c o p i n g style and

t r e a t m e n t t e c h n i q u e , which c l e a r l y w a r r a n t s f u r t h e r s t u d y .

C h i l d r e n ' s l n d i v & d u a l D i f f e r e n c e s

The c h i l d l i t e r a t u r e is less clear on i n d i v i d u a l

d i f + e r e n c e s , b e c a u s e of c h i l d r e n 7 s l a c k of s t a b i l i t y i n c o p i n g

s t y l e s a n d a g e n e r a l u n a v a i l a b i 1 i t y o f m e a s u r e s t o c l a s s i S y

3 1

coping disposition= and styles (Melamud, Robbins % Graves,

15T.22.

Ano the r personality dimension which has attracted research

attention in health studies is lorus of control. Kel lerman,

Zeltzer, El lenberg, Dazh F:igier <1'?80) cmnpat-ed hea,lthy

adolesrents with adole=cen.i-,s suffering from chrcnic ar sericms

di sea5.e~ an a number of psychologi cal dimensi ons including the

health locus of control Ci .em, the perception of their control

aver their health!. Health locus af control was not

5tati.itiraily significant in the diabetes rnellitus or cystic

Slbrosis graups. However-, some support was +ourid +or the

reduction a+ adolescent's sense of csonh-ol over his or her

future in relation to health +or patients .with oncology, renal

and rheumatic disorders when compared to heaithy adaiescent-s.

Despite the lack af specific inventories, Knight et ai.,

[ lW9) studied children's individual diifences using a ci inicai

interview and Rorschach data in order to classify children's

degree of de-fensi veness .towards their, hospital procedures. The

types of defences included denial, intellectualization,

displacement, projection, and isolation. The children were toid

what procedures they would encounter- during their hospital stay.

Their deiense reserve was assessed by the capacity to mobilize

greater defences when faced during the interview by ~ncreasingly

threatening situations. Physiological measures of cortisol

production wer-e obtained and these were found to be

significantly related to the Rorschach anxiety rat-ings. They

found that the children who coped mere success+ully used $

intellectualization with or without isolation and flexible

defenses. Children who used displacement, denial (with or

without isolation) ar projectie~ in 3 r;gid defence structure

Car-eful attention m u s t be paid'ta the way a chiid capes with stimuli in his environm~nt beCore he is prepared and hospitalized.. .While the child who intellectualized wanted to hear every detail of the upcoming e:.:perien~e~ =he children ~ h o denisd &ten covered theit- eat-s. trylng to block out all the iniormation. These latter children wouid probably da best with 1 ittle int~r-matien and a qt-eat deai oC supportive, nurturing care... i p . 4 7 j .

These findings have implications +or the manner I n which

parents and hospital stafS prepare chiLdren +or medxral and

surgical experiences. They also under1 lne the importance s+

rareiully assessing each child's rractions tg the strecsfui

experiences in determining appt-oprlate intervention. Beyond

rareiwl observation and cl inicial expertise, there are no

measures by which children's individual coping styles can be

determined. This area warrants further research and

development .

Behavi oural Techniques ------------------ --- The behavioural model has ad-vacated as its central

underpinnings, methoielological rigour in the observation and

measurement o+ behavi our and in the evaluation o-f behavi oural

therapeutic techniques. Over the last decade behaviour

theorists and therapists have turned their attention to

investigating the neglected area of pain.

The Sehavl~ural approach conceptualizes pa in as an

overt behaviour that can be in4Lueoced b y the same

as operant ii its occurrence was contingent an its

consequences, and not dependent upcn antecendent stimuf i a+

tissue damage or irritation. Such pain Sehaviocr idepender i t

on environmental respanses) qua1 i#ied as 1 chrsnic gala

condition. It is to this area that proponents af

behavi ouri s m have made a substanti a1 contr i S u t l an, and

where behavioural techniques have had greatest application.

In cont~ast, pain ?5ehaviuur was considered respcndent, ansd

thus acute, if its onset and frequency cd occurrence was

directly due to antecedent stimuli a$ tissue damage sr

irritation from disease or trauma.

The relationship between pa. in and a n x i e t y is a

complex one. Anxiety commanl y accompanies acute pain, and

the role of anxiety is considered paramount in the

treatment o+ pain. Turk (1978) noted that anxisty is

perhaps the earliest and m u s k canslsten%li, ide~tified

psychological mediator of the pain experience. The g-eater

the level uf anxiety, according to Sternbach ( l Q b B ) , the

greater will be the adverse reaction to a painful

situation. Same investigators have suggested that reducing

anxiety in and of itself would be su+ficfent to attentuate

7 4

t h e e x p e r i e n c e ob p a i n . Prorisely h o w anxiety relates ta

pain p e r c e p t i a n and re.sction still r e m a i n s ta be claribied

in the behaviour-a1 f r a m e w a r k .

An:: iety i 5 csnreptua l i z e d at a f earned p h e n ~ m e n o n

that c a n be e x t i n y u i d - e d b y l e a r n i n g a r e s p o n s e t h a t is

i n c o m p a t i b l e w i t h a n x i e t y fazr t h e particular situatian, I n

t h e deve lopmen t o i b e h a v i a u r a l t h e o r y and therapy, the

r e l a x a k i c n reqmnse a t t r a c t e d e a r l y attentian,

R e l a x a t i o n ---------- I n 1921, J a c u b s a n a p h v s i c l o y i s t , introbure4 a

p r o c e d u r e t o r e d u c e m u s c l e c o n t r a c t i o n s a s s o c i a t e d with

a r o u s a l . J a r a b s o n ' 5 p r a g r e s s i ve re1 a x a t i on technique, i ?

which s p e c i f i c m u s c l e g r o u p s are s u c c e s s i i v e l y t e n s e d 2nd

r e l a x e d h a s been u s e d i n adult t r e a t m e n t i u r many

c o n d i t i o n s i n c l u d i n g p a i n ( H i m m % Masters, 1979). An:r i&y

and p a i n have de-Fini t i v e p h y s i ~ l a g i c a l camponen t s such as

i n c r e a s e d h e a r t - r a t e and p e r s p i r a t i o n a s w e l l as a f t n - z d

r e s p i r a t i o n rate. R e l a x a t i o n t r a i n i n q can r e d u c e t % e

p h y 5 i o l o g i c a ? a r o u s a l t h a t o c c u r s i n a c u t e p a i n cortbi t i o n s .

Moreover , r e l a x a t i u n t r a i n i n g is often a compcment a+

a t r e a t m e n t "package" +or p a i n and a n x i e t y r e d u t 5 i a n

(Meichenbaum, Turk & Genest, 19831. Some i n v e s t i g a t u r s have

i n c l u d e d d e e p breathing e x e r c i s e s i n t h e i r b e h a v i o u r a l

i n s t r u c t i o n s a n d h a v e p o s t u l a t e d t h a t t h e s e e x e r c i s e s

e n h a n c e p o s t - s u r g i c a l r e c o v e r y ( J o h n s o n & i e v e n t h a l , z974).

C r i t i c s h a v e n o t e d however , t h a t t h e t h e a r e t i c a l

TC --. L)

explanations +or the b e n & i c i a l sf i e c t c 09 re laxa t ion are

not as clear-cut as the empiricai evidence a+ the

beneficial e+f ects n i the changed physi alogica? respcmsEs

lRirkard % Ef kins, 1 '?E3) . The l a c k o S 2.n adequate

theoretical explanati~n +or relaxatian may be yet a n o t h e r

instance in ~ h i c h our the~retiraf r n ~ 3 d e I ~ a+ t h ~ 'mind-body

interaction' are Saund wantiny.

Progressive relaxatisn training p r o c ~ d ~ r o s far

children have been develnped. Hickard and Elkins i19S3>

report success usinq relaxation with a diversity af

childhood stress-related disorders such as i e a r r , in~cmnia

and psychosomatic disorders. Relaxation is gaining rerent

attentian for its applicability to childhaud migraine

disorders. At the Children's Hospital of Eastern Ontario,

McGrath (1983) 1 5 c&rently evaluating relaxation tralnlnq

with 150 children,' (aged 9 ta ?7 years) who experience

migraine headaches an an average a i at least one per week.

The study compares progressive re1 axation with a

non-specific treatment and self-manitorinq. Outcame data

arc not yet available.

Other studies with children have incorparated

relaxation simply as breathing or blowing exercises as one

component in the treatment package (Jay, Elliott, Qrolins 8~

Olson, 1982: Psterson & Shigetomi, 1982; Zeltzer & LeBaren,

1982).

E~gaitive-Behavisural Variable: Distraction

In the early 19705, cognitive behaviourists diverged

r c O R S +rom main-stream behaviouri 5m by argui ng that cogn; +;

are learned responses and ccnsequently can a+Sect

behaviour. The cognitive behaviourists proposed that

thoughts and belie-Fs shsuld be examined and changed ii

therapeutic change is to occur. A number of researchers

moved away from investigating the classic behavioural

techniques such as relaxation and systematic

desensitization, and emphasized the examination o-f

cognitive variables such as belief systems, imagery,

relabel 1 ing thoughts, and distractim?.

The cmgnitive behaviaur madi-Ficatian procedures that

affect pain-related anxiety include attentlon-distraction

and strategies for reinterpreting or recanceptualiring the

painful stimulation. bdkmen undergoing chi f dbirth and

laboratory subjects indicated a strong preference +or using

distraction above monitoring sensations as a pain-coping

technique (Leventhal, Shachum, Boothe, & Leventhal , 1981; McCaul & Hauqvedt, 1982) The preference +ur using

distraction in acute pain situations has persisted despite

the empirical evidence that it is not as effective as

sensation moni toring (McCaul & Malott, 1984) . Distraction has a history for pain alleviation that precedes modern

research: the philosopher Kant offered the fallowing

example of his use o+ distraction (a5 cited in Meichenbaum,

Turk Genest, 1983).

For a year I have been troubled by morbid inclination and very painful stimuli which from others descriptions o i such symptoms I believe to be gout, so that I had tu call a

dactor. One night, however, impatient at being kept awake by pain, I availed mysel+ to the stoical means of concentration upon some different object of thauqht such for instance as the name of "Cicero" with its multifarious associatians, in this way I faund it possible to divert my attention, so that pain was soon dulled.....Whenever t h e attacks recur and disturb my sleep, I find this remedy m o s t useful (p.280).

In a review af studies using distractian to cape with

pain, McCaul and Ma1 ott ( 1984) expl ured the assumptions

underlying the use af distracti~n. The hypathesis that

distraction will reduce pain is based on the assumption that

the pain experience depends on in-formatiun prac~ssing;

distress results from attending to sensory inputs and

pracessing them in an emotional f ashian. Distractiun may

interrupt this process as long as attentiondl capacities are

limited ( p , S l 9 ) . They further suggest that relaxatiun,

meditation, acupuncture, hypnosis, and stress innocul ati on

could be conceptualized as producing relie+ from pain via

distraction.

OsfLs4fFns,and,Pr~cess-~f~QLztr_ac_2Lgn_

Distraction can be defined as diverting one's attention

away from the sensatians or reactions to a noxious stimulus.

The assumptions implicit in such a statement are that

cognitions are an important determinant of the pain

experience, and that there are limitations to one's

attentional capacities (McCaul b Malott, 1984).

Limitations to the attentional capacities, as well as

controlled versus automatic processinq of pain signals, are

concepts cited by McCaul & Malott (1984) to account for the

process of distraction in pain control. They maintained that

unlike automatic processes (those requiring minimal attentian

or awareness), control led processes ( i . e. , a conscious allocation of short-term memory store) are rapar i ty-baund.

Moreover, they advocated accepting the assumption that if

distraction is able to reduce distress, pain perceptiun should

b e considered a controlled rather than an a u t ~ m a t ~ r process.

If not. distraction would be ineffective, and pracfssinq and

responding to pain would occur without drawing on attentiondl

resources. Furthermore. d m - distractiun t~ be an ei+ective

technique McCaul % Malott postulated that it too must involve

a controlled process that absorbs part ~f the attznt:m-ml

resources, permitting the pain components to be pracessed by a

reduced attentianal capacity. Stimulus intensity was cited a5

a determinant of whether distraction wil f work. A painful

stimulus that increases, reaching intense levels. would

attract attention and impede the effectiveness of distraction

(McCaul & Malott, 1984). These concepts are among few

proffered in an attempt to provide an explanation of why. how

and when distraction could be effective.

Laboratory E v i denze

Laboratory research with adults has damnstrated

consistently that distraction is more sf f ective than no

treatment in reducing pain. Moreover, a wide variety of i

q attention-distraction techniques are effective +br pain !j

reduction (Barber & Cooper, 1972; Blitz & Dinnerstein, iQ71;

reduction associated with various types of experimentally induced distractions and also with Ss' own methods of distractinn (p . & S O ) .

Although rather difficult to implement, these

recommendations are basically sound, as several pain-producing

stimuli would more close1 y approximate the clinical and

real-life experience of some painful conditions ( e . g . , medical

procedures). Secondl y, since distraction may be e##ective far

only short periods, using a variety of distractors in place of

only one may be more appropriate to the attention process

(e-g., McCaul % Haudvedt, 1982). Furthermore, the distractors

that demand considerable attention may be the most effective

of a1 l (McCaul & Malott, 1974).

The next question to address in evaluating the

effectiveness of distraction is whether the impact of

distraction is greater than a placeba effect. Chaves -%. Barber

(1974) experimentally induced pressure pain and varied the use

of coping techniques and an experimenter model. Af ter the

pre-test trial, the subjects who were told to expect a

reduction in pain reported less pain that the cantrol subjects

who were given no instructions. The treatment group that were

trained to distract themselves with imagery reported even less

pain then the expectancy group. This evidence is supportive of

the hypothesis that distraction is m o r e than a placebo effect.

In a review of distraction and strategies that encourage

a non-emoti onal redefinition of monitored sensations, McCaul

and Malott (19841 suggested that attention shifts to the pain

sensations as the levels of pain increase. Consequently, at

the more intense pain levels distraction may no longer be

of+ective. They proposed an interaction a+ mild and intense

pain stimulus with distraction and redefinition of pain,

predicting that distraction would be more d-fective than

sensation redefinition for mild pain. However, in intense pain

conditions they expected that non-emotionally redefining the

sensations would be more e+fective than distraction. The

evidence that they examined did not clearly support their

contention, and they concluded "enough contrary evidence

exists to prompt caution" in the acceptance of an interaction

between stimulus intensity and treatment (p . 5281.

Comparing distraction with emotive imagery and a control

condition using col d-pressor stimulatisn, Horan and Del l inqer

(1974) showed that imagery may be more powerful than

distraction in reducing pain perception. While their hands

were immersed in ice-water, subjects in the distraction

treatment were instructed to look at the back door and count

backwards $ram 1,000; the emotive imagery group were provided

with relaxing cam-forting images (e. g., walking through a lush

meadow); and the no-treatment controls were simply instructed

to place their right hand in the ice water for as long as they

could tolerate. Although the findings were not statistically

significant, the subjects exposed t o pleasant imagery were

able to endure the ice water nearly three times a5 long as the

no-treatment control group and nearly twice a5 long as the

distraction group. Considerable subject variability was

displayed, regardless of treatment. This finding is consistent

with other laboratory pain stGdies, where large individual

differences appear to be commcrnly found (~ilqard S( Hilgard,

In summary, the studies showed that no one single

distraction technique has proved to be widely effective.

However, a variety of distract~rs was more effective than no

treatment or expectancy-placebo condition5. Distractors that

demand more attention may be more effective in reducing pain

perception. Evidence suggested that distraction tended to be

most effective for low levels of pain; and the proposal that

when pain reaches intense levels other techniques such as

sensation moni torinq or imagery involvement may be more

successf ul recei ved some support.

Thus, multi-modal techniques are suggested. One such

example of a treatment package is the cognitive-behavioural,

coping-skills model proposed by Turk, Meichenbaum and Genest

(1983). It is proposed as an interaction of cognitive,

affective and behavioural domains, and as such combines a

variety of techniques. The strategies included are

attention-diversion, monitoring the changing pain sensations

in the body, and imagery manipulation, such as changing the

pain experience using fantasy. Known as "stress inoculation"

this coping skills package for adults emphasizes "educating

the patient" and rehearsing the procedure before entering the

application phase.

!ZhLLs!rss~s,Stus!Lns

For obvious reasons laboratory studies with children are

uncommon, and in the area of pain research these studies are

non-existent, In the behavioural literature, pain studies

43

involving children and adolescents have been conducted in

applied settings (c-f., Peterson & Shiqatomi, 1981; Zeltzer &

LeBaron , 1982) . There is not a unanimous acceptance of distraction as a

viable treatment for children in pain. For example, McCue

(1982) stated "Most children need to attend closely to the

medical procedure in order to be able to integrate and master

it. No attempt should be made to distract the child or to take

his mind off the event" (p. 248). McCue has a narrow view and

disavowed the therapeutic deployment of distraction.

Unfortunately she did not provide any evidence to support her

claim that distraction has minimal utility for children during

painful medical procedures. A clue to her dismissal of

distraction may lie in her non-directive model of the

therapist-chi ld interaktion during painful procedures: The

child always provides the lead and the therapist follows

providing support, comfort, and acting as a "positive and

nondistractive example" to the parents. Moreover, the

non-directive method may be inappropriate for the younger

child. Gaunter to therapeutic intentions, the yaunger child

may become sensitized and more anxious in response to an undue

focus on each step.

In contrast, Jay, Elliott, Ozolins and Olson (1982)

developed a multi-component treatment package based on the

stress inoculation model, that prescribed a more active

training role for the therapist, which went beyond providing

basic support and com-fort.

Psychological intervention was provided 45 minutes prior

t o t h e c h i l d ' s medica l p r o c e d u r e and c o n s i s t e d of f i v e

t e c h n i q u e s . Because t h e t h e r a p e u t i c t e c h n i q u e s implemented

d u r i n g t h e p r e p a r a t i o n and p r o c e d u r e are r e l e v a n t ta t h e

p r e s e n t r e s e a r c h i t is u s e f u l t o examine them c l o s e l y .

1. The c h i l d r e n w e r e t a u g h t a b r e a t h i n g e x e r c i s e w i t h

i n s t r u c t i o n s t o

p r e t e n d t h a t y o u ' r e a b i g round tire. Take a deep b r e a t h and f i l l t h e t ire w i t h a s much a i r as p o s s i b l e , t h e n s l o w l y let t h e a i r o u t making a h i s s i n g sound as t h e a i r g o e s o u t of t h e tire.. . (p .9 ) .

T h i s w a s used t o i n d u c e r e l a x a t i o n d u r i n g t h e a v e r s i v e

s i t u a t i o n as w e l l a s act a s a d i s t r a c t i o n so t h a t t h e c h i l d

c o u l d a c h i e v e a s e n s e of a c t i v e m a s t e r y o v e r p a i n or a n x i e t y ,

r a t h e r t h a n p a s s i v e l y s u b m i t t i n g t o t h e p r o c e d u r e s .

2. Reinforcement t o o k t h e form of a s m a l l t r o p h y w i t h t h e

c h i l d r e n ' s name e n g r a v e d - o n it. The t r o p h y would b e g i v e n " t o

c h i l d r e n who a c t e d v e r y b r a v e d u r i n g t h e p r o c e d u r e s " , l a y

still and d i d t h e b r e a t h i n g e x e r c i s e s .

3. Imagery w a s i n c l u d e d as a c o g n i t i v e s t r a t e g y . The a u t h o r s

p r o v i d e d t h i s example:

P r e t e n d t h a t Wonderwoman h a s c o m e i n t o your house and t o l d you t h a t s h e w a n t s you t o b e t h e newest member of h e r superpower t e a m . Wonderwoman h a s g i ven you s p e c i a1 powers. These s p e c i a l powers m a k e you v e r y s t r o n g and tough so t h a t you c a n s t a n d almost a n y t h i n g . She a s k s you t o t a k e s o m e tests t o t r y o u t t h e s e superpowers . The tests are c a l l e d bone m a r r o w a s p i r a t i o n s and s p i n a l t a p s . Those tests h u r t , b u t w i t h your new s u p e r p o w e r s you c a n t a k e deep b r e a t h s and l i e v e r y still. Wonderwoman w i l l b e v e r y proud when s h e f i n d s o u t t h a t your s u p e r p o w e r s work and you w i l l b e t h e newest member of h e r superpower t e a m (p. 1 1) .

These "emotive images are used t o i n h i b i t a n x i e t y . ..and

presumably t r a n s f o r m t h e meaning o+ p a i n f o r t h e c h i l d and

e l ic i t c u r r e n t c o n c e r n s which are r e l a t e d t o m a s t e r y of p a i n

r a t h e r t h a n avo idance" (p .11) . I n t h e p r e p a r a t i o n p e r i o d , t h e

imagery w a s t a i l o r e d t o e a c h c h i l d ' s h e r o p r e f e r e n c e s so t h a t

d u r i n g t h e medica l p r o c e d u r e s t h e c h i l d r e n c o u l d b e reminded

a+ t h e imagery s c e n a r i o and coached t a d o t h e imag in ing , +or

example "Remember Wonderwoman - what would she d s r i g h t now?"

4. Eehavi mural r e h e a r s a l $01 l awed t h e t h r e e a f o r e m e n t i oned

e v e n t s and t h e r e h e a r s a l of t h e medica l e v e n t o c c u r r e d i n

t h r e e d i f f e r e n t ways: The c h i l d p l a y e d d o c t o r and g a v e a d o l l

t h e p rocedure ; t h e c h i l d t h e n g a v e t h e BMf3 or LP t o t h e

psycha l og i 5t ( t h e a u t h o r s n o t e , w i t h o u t t h e u s e of n e e d l e s )

who modeled c o p i n g b e h a v i o u r s ; and f i n a l l y t h e c h i l d p r a c t i s e d

undergo ing t h e p r o c e d u r e and w a s coached by t h e p s y c h o l o g i s t .

k c t u a l medical k i t s u sed by t h e p h y s i c i a n w e r e used. The

a u t h o r s m a i n t a i n e d t h a t t h e s e p r a c t i c e 5 e s s i o n s h a v e s e v e r a l

t r e a t m e n t components; i n f o r m a t i o n a b o u t t h e p r o c e d u r e ,

model i n g of c o p i n g b e h a v i o u r s , i n v i v a d e s e n s i t i z a t i o n

t h r o u g h g raded e x p o s u r e t a t h e n e e d l e s and materials employed,

and r o l e - p l a y i n g t h e p rocedure . They m a i n t a i n e d t h a t t h e

r e h e a r s a l may h e l p t o f a c i l i t a t e i d e n t i f i c a t i o n w i t h t h e

p h y s i c i a n and g e t t h e c h i l d m e n t a l l y r e a d y +or t h e a c t u a l

p rocedure .

5- For c h i l d r e n aged A t o 10 y e a r s , a 12-minute + i l m m o d e l l i n g

a d a p t i v e c o p i n g w i t h a BMA by a 6-year-old w a s i n c l u d e d .

Ten s u b j e c t s (aged 3.5 t o 9 y e a r s ) , who e x h i b i t e d h i g h

l e v e l s of a n x i e t y f o r BMAs and LPs w e r e g i v e n t h e t r e a t m e n t

package. The c h i l d r e n w e r e f i r s t obse rved and r a t e d on t h e

O b s e r v a t i o n a l S c a l e of B e h a v i o r a l D i s t r e s s (OSBD) t o o b t a i n a

baseline measure of behavioural distress. With their 1 imi ted

number of 10 subjects, a staggered baseline design was used,

with each subject serving as his or her own control, and

pre-and post-intervention distress scores were graphed.

Results indicated that 9 of the 10 subjects had 40% less

distress scares in the first intervention session. Precise1 y

how this figure is arrived at is not made clear. However,

visual inspection of the +iqures indicates a substantial drop

between baseline and intervention. There is also substantial

variability in the maintenance of these e + f e c t ~ for the

subsequent intervention sessions. Distress levels increased

during the following intervention procedures for 4 of the 10

subjects, and effects were maintained for a fur the^ 4 of the

10 subjects. One subject requested "no intervention" and only

one subject improved oh subsequent interventions. Apart from

the graphs, no tables or statistics were reported in this

study, and thus any conrfusions are best considered

impressionistic.

The high individual variabi l ity of the treatment

sessions f 01 lowing the first intervention session is very

curious. The authors suqgest that these "relapses" may have

been due to the reduced novelty of the subsequent treatment

procedures, or to individual differences in expectancies:

"Some patients seem to form unrealistic expectations that all

pain will be taken away by the use of the coping techniques

taught them" (p. 181. They also noted that two of their

subjects exhibited a "repressor" cognitive-style in which they

seemed to want to avoid the specific procedure information and

resisted behavioural rehearsal. They recommended that

techniques more consonant with these styles should be used, if

these individuals can be identified prior to intervention.

This study, with its limited number of subjects and

d&cri pti ve statistics, is methodological ly unsound but does

embody the constituents of a child-centred treatment proqram

to reduce anxiety and train children in coping with painful

EMAs and LPs. The treatment package may however suffer from

overload. Too many new things are offered too quickly during

the highly charged 45 minutes before the dreaded event, the

painful medical procedure. Moreover, the proqram appears to

emphasize mastery over the EMA and LP, rather than increasing

the level of coping skills. With analogies of heros and

trophies to be won, it* is indeed likely that children would

have high expectations of success. This may indeed account- for

the unstable maintenance of treatment effects a+ ter the first

treatment. This suggests that future techniques should avoid

over-emphasizing mastery and focus on developing realistic

coping ski 11s that can reduce, but not necessarily eliminate

pain.

The use of actual medical kits for the behavioural

rehearsal is questionable for children, if not also for some

adults. The equipment could look terrifying to a child; the LP

needle is long, and a thick steel aspiration needle is used

for the BMA. Both could induce anxiety in the most

we1 1 -prepared individual.

Theoretically the consideration whether to expose

patients t o the actual medical equipment involves the issue'of

individual differences and "repressor" and "sensitizer" coping

styles. Since repressors are patients w h o cope better with a

5tressful event by avoiding it, and sensitizers cope better by

attending t o in+ormation about it, providing the child with

the. actual equipment shrl~uld only suit the sjensitirers. It

should be countertherapeutic for the repressors. Lipowski

(1970) noted a complication +or some adult sensitizers. A s a

result o# their hyper-vigilant cognitive style, they are .

anxiety-prone and obsessional. These sensitizers would briskly

process information about the needles and procedure and may

exaggerate the threat to their physical integrity. Whether

this pertains t o children a s well ha5 not a s yet been

determined. However the possibility that for children with a

sensitizing coping style, exposure t o medical tools could

heighten anxiety and feed into'fears of being hurt, cannot be

ignored.

It appears that Jay et dl. " s work has promise, but it

could be improved by a "dismantling" approach. In their

study, it is difficult t o assess which component of the

packag'k was more effective. However, they do acknowledge the

need t o isolate the ef#ective components in this package, and

drop others to make a more efficient cost-effective package.

Furthermore, the authors have not satisfactorily

specified the therapeutic process dgrinq the procedures. The

process is not standardized and the therapist may jump from

one technique to another, guided by no deliberate lor

reliable) therapeutic plan. An identification of which

treatment component ta use at which particular stage of the

medical procedure would be important. The strength of this

treatment package is in its recognition of the importance of

preparation prior to the procedure. Because this is a hiqhly

charged time for both parent and child it is probable that a

lower-key approach, without potentially sensitizinq material,

such as needles, could have greater success.

Y~enntbrner

Y~esssiz,as@,Pais,BeL.i~f~~,HLs2,oci1=aI~e3~~~~%~~

Hypnosis has been found to make an impressive

contribution to pain relief (Hilgard & Hilgard, 1975). However

contraversial claims and exaggerations have led to a history

of f 1 uctuati ng acceptance of hypnosi 5.

"The modern history of hypnosis begins with Mesmer, an

Austrian physician whase interest in the healing power of

magnetic influence was a logical extension of attention to

magnetic barces among astronomers and physicists of that time"

(Gardner & Qlness, 1981, p . 7 ) . Mesmer postulated a theory of

animal magnetism and his techniques included staring into his

patients' eyes and making "passes" with his hands over their

bodies. There were claims for the success of "animal

magnetism" as an analgesic, which permitted surgery without

pain, and as a cure far blindness, melancholia, and other

ailments.

Concern for "miracle cures" led the scientific community

Of the time to press for an investigation of animal magnetism.

In 1784, King Louis XVI appointed a c~mmission under the

American Ambassador, Benjamin Franklin, to investigate

Mesmer" s claims. The commissian concluded that "the effects

observed were more parsimoniously attributable to the

imaginatian (used pejoratively) a$ the magnetized persun, than

to any invisible animal magnetic agent" (Perry & Laurence,

1983, p.354). In short, imagination was the "true cause" of

these effects.

Over the last 30 years the researchers and practioners

af hypnosis have attempted to divorce it from mysticism,

magnetism, and magic. A sizeable body of clinical and

laboratory research has accumulated and there is convincing

evidence on the applicability of hypnosis to a wide range o-f

pediatric pain conditions such as burns (Wakeman & Kaplan,

19781, encopresis (Olness, 19761, cancer (Hilgard & Morgan,

1976; Hi lgard & LeBaron, 1982; Kel lerman, Zel tter, El lenberg b.

Dash, 1983; LeBaw, Hal ton, Tewell & Eccles, 1975: Mi 1 ler, 1980:

Zeltzer & LeBaron, 6982). The clinical evidence that hypnosis

can be helpful for many patients in reducing pain is now

convincing (Hilgard, 1975). A great deal of the evidence for

pain re1 ief has come from laboratory experiments.

Labsratsrr,E~Lbs~re

There has been some controversy whether hypnosis is

anything more than placebo, or relaxation response. Using a

simulation hypnosis group, Shor (l9&7; cited in Hilgard, 1975)

examined physiological responses to electric shock with highly

susceptible hypnatized subjects, under conditions that

minimized anxiety. The t w o groups (one consisted of simulators

and the other consisted o-f hypnotized subjects) evidenced a

reductian in physidogical responses during the

anxiety-reduction condition, but their experience of pain was

not lessened. During the experiment there were na detectible

differences in pain behaviour between the real and the

simulation qroup. In the post-experimental inquiry however,

the hypnotized subjects reported that they had felt no pain,

while the simulat~rs had #elt their usual amount of pain. The

analgesic effect of the hypnotic suggestion was demonstrated

ta be a separate issue from the anxiety-reducing, ar

relaxation effect. The hypnotizable group experienced 1 i ttle

or no pain, unlike the n~n-hypnotizable group.

The hypnosis effect can also not be fully accounted for

by the placebo response. In an experiment which induced

ischemic pain in the arm through the tourniquet-exercise

method, McGlashan, Evans and Orne (l9&9), found that the

placebo had a pronounced effect for the non-hypnotizable

subjects, but was ineffective for the highly hypnotizable

subjects. Furthermore, both the placebo and the hypnotic

analgesic had a similar effect for the non-hypnotizabl e

subjects. Only the highly hypnotizable group demonstrated a

dramatic pain reduction with hypnotic analgesia. For the

highly hypnotizable, the hypnotic process seems t o be

dif4event from a placebo condition and the correlation between

the two conditions was neglible. 'For the non-hypnotizable

graup the hypnotic syggestions appeared t o act like a placebo

and there was a high correlation between these two conditions.

This study suggests that for the high1 y hypnotizable, hypnosis

and a placebo suggestion are different conditions; for the

non-hypnotizable there may be an overlap between placebo and

hypnosis in the control of pain.

Y~enoti~,S~zseetibiLi%~

Hypnotic susceptibility is regarded as a relatively

stable characteristic o-f the individual although stable

personal i ty correl ates have been elusive. Measures of

hypnotizability appear t o index the degree to which an

individual can set aside critical ,udgement and became

absorbed in the hypnotic suggestions. People dif-fer in the

degree of their response to hypnosis, and hypnotic

susceptibility is normally distributed. It has been

demonstrated that 10% t o 15% of the populatisn are highly

responsive t o hypnosis (Hi lgard, 1975).

There is some controversy a s to whether hypnotic

responsiveness is a trait or a state phenomenon. Some

researchers (e.g. Barber, 1979) contend that if there is na

formal hypnosis (induction preceding hypnosis), the subject

cannot be said t o be in hypnosis. However, others (Gardner

Olness, 1981) argue that certain kinds of behaviours such a 5

hand 1 evi tation, or visual ha1 1 ucination can be described as

hypnotic behaviours. Individuals will vary in terms 09 the

antecendent conditions necessary to experience hypnosis, as

well a s in their ability t o experience the different kinds o-f

hypnotic phenomena. The common position that hypnosis is both

a state and

study. This

a trait phenomenon has been adopted in the present

means that subjects differ in their ability t o

respond to hypnosis and that the state a+ hypnosis differs

from normal consciousness and cannot be completely accounted

for by demand chararterlstics (Hilgard E Hilgard, 1975; Orne,

1972).

Tests of hvpn~tic responsiveners consist of suggestions

to which hypnotized people are known te respond, such as hand

levitation. The scores are relatively stable gver time but do

not correlate with any personality variable. Hi lgard & Hilgard

(l?i'5) pursuing the correlates of hypnosis in their laboratory

interviewed students before they were hypnotized, in an

attempt to predict how hypnotizable they would be. They found

that "imaginative involvements" during childhood were

emphasized by the subjects who were highly hypnotizable.

Elaborating on this concept Hilgard & Hilgard write:

Imaginative involvements may be in reading, in dramatic viewing or acting, in music listening or performing, or in some form of adventure. The person who becomes involved temporarily sets ordinary reality aside to become totally absorbed in the imaginative experience: he finds his absorption re+reshing and who1 1 y satisfying.. . .But the departure from reality is temporary, and the person returns to his normal coping with external reality. Those who habitually had such experiences proved to be among the most hypnotizable, while those who could report Csomc experiences3 none af them were among the least hypnotizable. (p. 111

- Imaqinati ve i n v d vement was i dentif led as a precursor of'

hypnotic ability. J.R. Hilgard (19791 has described

imaginative involvement as the skill underlying hypnotic

responsiveness. Research has further refined this notion of

imagination. Imagination with the f 011 owing components,

imagery, absorption and dissociation is the type that is

responsive to hypnasi5 (Hi lqard, E., 1974; Hi lgard, 3. R.,

1973; Tellegen & Atkinson, 1974).

There is a parallel between hypnotic responsiveness and

imagination development. Drawing cm child-development

literature, Hilqard & LeEaron (19823 trace the development of.

imagination from "pretend-play", which is imitative play and

is exhibited before two and a half years a+ age, to

socia-dramatic play, exhibited between t w o and a half and five

years and manifested in interaction with others. 2nd finally

t o school-age where a more mature level is manidested, when

the child is "capable 04 the internal elaboratim z f rich and

diverse images in the form oS free-fantasy" Ip . 419). The

develu~ment of imagination thus greatly resembles the early

stages ob the hypnotic ability.

Perry and Laurence (1983) in a perceptive historical

evaluation of hypnosis, surgery and mind-body interartion,

comment on the. role of imagination, saying that

Common t o many theoretical accounts o-f hypnosis is the focus upon the role of imaginative skills that are suf+iciently developed and encompassing a s to be able t o supercede realistic, luqical thaught. It is a5 I f we have returned full circle t o the conclusion of the Franklin cummission, but with certain major dif3erences. Imagination is not conceived of in perjoritive terms, and more importantly, hypnotizabil ity is recognized a s a differential phenomenon. Ta the extent that a person has this particular kind of imaginative skill, he or she will '

be able, under certain favourable conditions t o set asid= critical judgement, exercise the skill at a high level of intensity and experience major distortions of perception, mood and/or memory. (p. 368)

The relationship of hypnotic susceptibility t o treatment

success has been described as a probabilistic one (with a

correlation of 0.50) . The more hypnotically responsive 'an '

individual is, the more likely it is that h e or she will

respond favaurably to an hypnotic intervention (Hilgard 3

. Hilqard, 1975). However, these data also indicate that some

individuals of law susceptibility may respond equally well to

a hypnotic intervention as d o high susceotibles, and

furthermore that high hypnotic suscgptibility will not

guarantee symptom alleviation when a hypnotic treatment i5

prbvided- This puzzle remains currently unresolved (Ferry b

Laurence, 1983).

tjypnotizability in children

Children shift very easily +ram one cognitive state to

another. The bounds of reality and fantasy are frequently

blurred and occurrences such as imaginary playmates during a

child7s waking activity are not uncommon (Hilqard, 3 . . lQ79).

The child below the age of six in particular, appears to

experience a continuum of cognitive states. At one extreme

there is an alert "here-and-now" reality-bound awareness; in

the intermediate state there is imaginary play involvement in

which reality and fantasy blend comfortably together; and on

the other extreme is the hypnotic trance in which the child

demonstrates greater responsiveness to suggestions and

significant alterations in sensation, perception and memory

(S. LeBaron, personal communication, July, 1982).

In contrast to adults, hypnotic states in children are

not as clearly defined, readily sustained, or easily measured.

Researchers (Hilqard & Morgan, 1976: Hilgard b LeEamn, 1982;

Gardner % Olness, 1981) emphasize that for the younger child

in particular, the hypnotic state may appear different to the

relaxed, detached state that adults and alder children

exhibit.

It has been recently recognized that younger children

readily enter trance states. Prior to the 1960s it had been

widely held that children under the age of six were not

hypnotizable. However, Morgan and Hilgard (19791 tested normal

'children aged 3 to I& years and found that "the child under

six i 5 hypnotizable, but not according ta the same practices

commonly used with older children" {p. 154). An active

participation in an informal manner between the adult and the

child was needed to initiate and sustain the hypnotic fantasy.

By the age of six, the child's imaginative ability had

developed sufficiently for the child to sustain the fantasy

himself. Imaginative involvement emerged as a central factor

in this process.

Morgan and Hilgard (1979) developed a short scale oS

hypnotizability, the Stanford Hypnotic Clinical Scale for

Children (SHCS:ChildI that is applicable to children four

years or older. In developing the scale they presented data

that demonstrated that during hypnotic induction children of

three and four years did not like to relax or keep their eyes

closed. This characteristic was important because-the standard

relaxation induction requires eye closure and relaxation, and

this was unacceptable for the very young child, who "needs to

keep track of his environment" (p. 150). Many five and six

year-alds likewise resisted keeping their eyes closed: and

while seven and eight year-olds would comply with the

instruction, a clear preference for eye closure was only

reached at eleven years of age. Nevertheless the researchers

found that the hypnotic responses {e.g., arm rigidity, visual

and auditory hallucination) were achieved with the child2s

eyes open.

During the hypnotic items, the authors also noted that

the children demonstrated a need for active motor involvement

(e.g., during the visual hallucination, a four year old boy

reported seeing Batman; and when he was asked what was going

on, he got up from the chair, said Batman was flying over the

city, and began waving his own arms a s he became Batman).

They concluded with the recommendation t o use an

active-imagination induction for the young child, that is

suggestions are given t o become involved in fantasy about

participating in a favourite activity. The peak of

hypnotizability o c ~ u r j in middle childhood, eight t o twelve

years of age {London b Cooper, 1962; Morgan 8 Xilgard, 1973).

EefinLtion,nf,Y~ens~Ls-Ln_~ChhLd,c~n

As yet there are no absolute data on the boundaries of

hypnosis. The problem of defining hypnosis for the young

pre-school child is particularly difficult, since the formal

characteristics of hypnosis are inapplicable. Gardner (19771,

in reviewing this issue, noted:

In the absence of the usual criteria for defining hypnosis (response t o a formal induction or score on a scale), one must rely on observations o+ certain behaviors of the young child which are similar t o behaviors associated with hypnosis with adults. These include (11 quiet, wakeful behavior, which may or may not lead t o sleep, f 01 lowing soothing repetitive stimulation which is a primary characteristic of most formal induction procedures, (21 involvement in vivid imagery during induction in childhood

beyond infancy, (3) heightened attention to a narrow focus with concomitant a1 terations in awareness, (4 ) capacity to follow post-hypnotic suggestions as evidenced by behavior which deviates from what is known to be the child"^ usual behavior in a particular situation, (p . 159)

Thus, the guidelines of whether a child is in an

hypnotic state remain those of the adult hypnotic state and

include a narrowing of attention, absorption in vivid imagery,

and a quietening of behaviour.

Clinical Studies 09 Children with Cancer

One of the earlier clinical reports of hypnosis for

children with cancer was a 24 month study a+ 27 children aged

four to twenty who were trained to self-induce their

hypnotic-trances iLeBaw, Holton, Tewell % Eccles, lW'5).

During trance the following aspects were encouraged: more

rest, easier sleep, adequate food and fluid intake as well as

greater tolerance for and ability to deal with LPs, BMks and

intravenous therapy. The subjects were given training in group

and individual sessions and they were asked to carry out

self -hypnosis on their own. A progressive body re1 axation

method was used as the induction technique, followed by

restful images such a5 a tranquil mountain view. Reference to

"sleep" was avoided, as the children were very literal.

Because there was no comparison group and the authors at

times found objective evaluation difficult, generalizatiuns

from this study are difficult. Nevertheless, the authors'

opinion was that this adjunctive treatment had a positive

effect ; anxiety, fear, depression, and anticipatory vomiting

appeared to diminish. A s a comment on the advances in medical

treatment made over the last decade, there was a great loss of

subjects through death when this study is compared to later

studies in this area.

hnother early report of hypnosis for children with

cancer was Hilgard and Morgan's (1976) presentation on the

hypnotic treatment of anxiety and pain in childhood cancer.

Thirty-six patients (aged 4 to 19 years) had been referred +or

various problems from pain and anxiety associated with LPs,

BMAs, intravenous injections, changing bandages and continuous

pain, They found that the clinical problems were extensive.

Most of the children had had repeated pain+ul procedures, and

anxiety was present not only in the child but in family

members. With the range of referring problems and differences

in ages, Hilgard and Morgan could not standardize their method

across all children and different criteria for outcome had t o

be adopted.

Of the three children referred for continuous pain, the

two who were highly hypnotizable were able t o reduce pain

completely during hypnosis. They were however, unable t o

sustain this re1 ief after the hypnosis ended, despite

post-hypnoti c suggesti ans or using self-hypnosis. Ten of the

16 children referred for BMAs and LPs were aged 4 to 6 years

old, and manifested extreme levels of anxiety. Both issues

proved to be problems for the researchers who were following

standard hypnotic procedures. Only 1 of the 10 young children

improved with intervention; this child was highly responsive

on the hypnotic scale. Four of the 6 older children responded

t o hypnosis, From these results the authors provided some

he1 pf ul pointers:

Children iaged 4 to 6 years) are more responsive t o a

kind of "protohypnosis", as Cormal hypnosis is inappropriate.

The young child is most easily absorbed "by listening to a

s t o r y or by participating in a verbal game with a friendly

adult, than by removing himself from the scene through his own

fantasy or through re1 iving an.. .experience on his own. " (p.

286

Hilgard and Morgan added that anxiety can be

successfully reduced using relaxation and distraction methods

without involving hypnosis; however, once this is achieved the

child is then in a better position to learn t o reduce pain

using hypnotic analgesia. Implicit in the above statement is

the authors' contention that distraction and relaxation

methods alone cannot successfully reduce pain. They advocated

a hypnotic technique in which selected "switches" in the brain

are turned down using the imagination. Sensitivity to pain is

reduced. (The switch technique is described in detail in

Appendix A).

Hilgard and LeBaron (1982) refined the process of

hypnosis with young children in acute pain, and improved the

research methodology. Their study wi 11 be examined close1 y

because of its exposition of hypnotic techniques and

therapeutic process. Twenty-four children with leukemia (aged

6 t o 19 years), who found BMAs distressing, volunteered to

participate in the study. Sixty-three patients were seen for

baseline observations. A surprisingly high number, 1 8 (i . e., 29x1 gave self-reported pain levels of 2 or less on a scale of

10, and were therefore not included in the study. These

pat ien ts had learned t o cope by themselves or wi th the help of

t h e i r parents or the nurses.

The ch i ldren were tested f o r hypnot izab i l i t y and

basel i ne observatl ons of t h e i r pain and anxiety behavi our were

taken during the BMA by an observer. Anxiety was assessed only

during non-pain periods (defined by the absence of needles).

Two independent judges then rated these pain and anxiety

repor ts on a scale of 1 t o 10. Self-reports on the leve l of

pa in only, were obtained on the older ch i ldren using a scale

of O t o 10, and on the younger ch i ldren using p ic tu res 09

f ac i a1 expressions. On1 y the pain s e l f -report measure was

selected, because during pre-test ing the researchers found

tha t the young chi ldren were confused between the notions of

anxiety and pain, and moreover, the pain experience tended t o

dominate t h e i r reco l lec t ion a f te r the procedure.

The hypnotic treatment followed a basic pat tern but was

ind iv idual ized f o r each pat ient . Hi lgard and LeBaron provided

a number of case studies t o i l l u s t r a t e the hypnotic technique:

f o r example, the case of 6 year o l d Annette who had rated

herself 7 f o r pain, and been rated 7 by the judges.

Hypnosis was induced by the eye-closure method, using a "funny-face" orl her thumbnail as a f i x a t i o n target. Subsequently she visual ized candles on a bir thday cake, blowing them out whi le squeezing her mother's hand. The hypnotic rehearsal o f the t o t a l procedure was then carr ied out. While hypnotized Annette was asked t o move t o a treatment t ab le t ha t w a s i n the o f f i ce . The therapis t 's co ld hand was used t o simulate the s t e r i l e wash, and each fu r the r step of a t yp i ca l bone marrow aspi rat ion was simulated. The area w a s pinched hard t o simulate a needle while she blew out the candles on the hal lucinated bir thday cake. A t the same t ime she squeezed her mother's hand and put a l l the fee l ings she wanted t o get r i d of i n t o tha t squeeze. She was e n t i r e l y co-operative throughout the hypnotic

rehearsal, and when she went in a little later for the actual bone marrow procedure, everything went smooth1 y, . . .During the aspiration of the marrow, she blew hard on the therapist's fingers which had become "birthday candles". At the end of the procedure she squeezed the therapistPs hands and smiled. She was pleased with herself and immediately wanted t o go downstairs t o play. (p.424)

Following the procedure, she rated herself 2 for pain, and the

judges rated her 1 for pain and 1 for anxiety.

In contrast for 9 year old Mary, a highly hypnotizable

child who had an extremely high level of anxiety, a

desensitization procedure was used prior t o implementing the

hypnosis rehearsal of the procedure.

She was taught t o relax through breathing exercises, and then gradually t o visualize images which reminded her more and more of having a bone marrow aspiration. If she became worried at any point she was t o squeeze the therapist's hand. The visualization would be stopped and a feeling of pleasant relaxation would again be reinstated. When it was clear that much o+ her general anxiety was controlled, in 20-25 minutes she was hypnotized...Asked what she would most like t o do' while hypnotized, she proposed visiting with Bambi, the deer. The posthypnotic suggestion was given that she could repeat the experience following her entrance into the treatment room...During the sterile preparation, she complained that the smell of alcohol was making her scared. The therapist responded by asking Mary t o see the beautiful roses along the path where she was seeking Bambi and t o smell them. The alcohol turned into the fragrant aroma of roses, as she continued her fantasy and she had no more trouble until the actual bone marrow needle was inserted when she cried out, "Oh, no I can't!" Once the aspiration was completed, however, she became calm and returned t o her imaginative involvement with Bambi. She had not required restraint at any time. She reported that the needle did not hurt at all; she had been frightened because she had felt a big poke, but it did not hurt her. (p.434)

Mary's self-report pain score dropped from 8 at baseline, t o 1

after the first treatment.

Results for the 24 subjects were obtained by comparing

baseline with treatment observations, with each subject

serving a s his or her own control. Na comparison group was

used. The average self-report pain score at baseline was 7 and

after- the hypnotic treatment the average score was 5, a

statistically significant drop, Pain reduction between

treatment 1 and 2 was non-significant. No standard deviation

scores were provided, so the variability of scores could not

be examined. The judges rated the pain scores somewhat lower

than the patient's scares, however a visual inspection of the

graphs suggested a high correlation between the two ratings,

The judges7 basel ine-to-treatment 1 pain scores were

significantly different at p<,OOl. The reduction between

treatment 1 and 2 was not significant. Qnxiety scores were

likewise significantly reduced between baseline and treatment

1, with a non-significant reduction between treatment 1 and 2,

It appears from the results that the children most able

to reduce pain with hypnosis will demonstrate this in the

first hypnotic session, The authors divided the subjects who

were successful in reducing their pain by 3 or more points

into prompt and delayed respondents, on the basis of their

self -report pain scores, The mean reduction was the same for

both groups (4.51; the first group of 10 responded immediately

to the first treatment and the second group of 5 achieved the

major pain reduction on the second treatment.

Of equal interest were the remaining 9 patients who

reported that they were unsuccessful in reducing pain using

hypnosis. There was, however, a drop in their judged level of

pain f 01 lowing treatment which reflected a reduced expression

of pain. Hilgard and LeParon explained this drop in judged

pain by saying "psiychological treatment which is presented in

the form of hypnotic intervention may have beneficial results

that are not attributable t o hypnosis per se" (p.429). They

elaborated this in their "two-component interpretation of

success". The first component dealt with relaxation and

anxiety-reduction "for which hypnotic talent is helpful but

not necessary" Ip. 438). The second component dealt with the

reduction of sensory pain which had a correlation with the

patient's hypnotizability.

Hilgard and LeEaron's study has import and relevence to

the present study for a number of reasons. It gave substantial

attention to the process of hypnosis with children, to the

necessity for individually tailoring the techniques to the

child's needs and to the therapist's flexibility in applying

these techniques. It emphasized that if a child has a high

level of anxiety, this should be dealt with prior to any

hypnotic intervention. It used a rehearsal of the procedure

(sometimes during hypnotic trance) and provided the child with

active coping strategies to use during the medical procedure.

Hypnotizabi 1 i ty was emphasized as being essenti a1 to

reduce felt pain, and while this was supported by their data

on the hypnotic scores of their subjects, it is a more

contentious issue and possibly cannot be answered in one

study. The authors attempted to strike a balance between

qualitative and quantitative findings (which is commonly not

done in clinical research). While they excelled in the +ormet-,

their statistics remained largely at a descriptive level.

The strengths of the Hilgard and LeBaron work lie

primarily in the development and application o-f clinical

techniques t o reduce pain and anxiety. The approach was

accommodated t o meet individual needs. A s the examples

illustrate, some of the patients were given facets of

behavioural therapy, such a s desensitization and re1 axation

training before hypnosis was introduced. Hypnotic treatment

was thus confounded by other treatment components. Since there

was no comparison group to control +or non-hypnotic

influences, conclusions about the efficacy of hypnosis alone

cannot validly be drawn from this wurk. Nevertheless the

composite of behavioural and hypnotic techniques emerge as

beneficial and effective.

In sum, Hilgard and LeBaron's study broke new ground. It

demonstrated that therapeutic intervention that is active,

combining hypnotic and -behavioural techniques and appl ied

during the procedure can have qualitative and quantitative

benefits for children in pain. Moreover, the impact of

therapist as a legitimate effective professional during the

surgical procedure had not been previously demonstrated.

4-C~mearatLve,Stud~~~Be_h,av_i~u_ra_1~an_@-H~efis&Ls-Es&heds~

The final study t o be reviewed, Zeltzer and L e g a r m

11982), provided the initial impetus and central

methodological and therapeutic guidelines for the present

study. For this reason a review and close examination of its

methodology and findings is useful t o provide both comparison

and contrast points. Zeltzer and LeBaron (1982) compared the

effectiveness of hypnosis and nonhypnotic techniques in

reducing pain and anxiety during BMAs and LPs. CJf the 45

chi ldren i n i t i a l l y seen, 12 reported no need fo r intervent ion.

The remaining 33 were aged 6 t o 17 years, wi th a mean age of

10.06 years (s.d.= 3-17); 27 o-f these subjects had EMAs and 22

had LPs.

The design consisted of 1 t o 3 baseline observations

followed by 1 t o 3 in tervent ion sessions, Mean ra t i ngs o f the

pre-intervention sessions on pain and anxiety were compared

w i th the mean ra t ings of the subsequent in tervent ion sessions.

LP and PMA procedures were analyzed separately.

Self-report scales and observer's judgement r a t i n g

scales were used t o measure pain and anxiety. The self-report

scales consisted of 1 t o 5 po in ts il=none, 5= maximum). This

comprised the pre-intervention data. Independent observers

a lso rated behaviour during the procedures using a s im i la r

scale. Correlat ions between the observers' and pat ien t 's

scores on BMAs was 0.56 f o r pain, and 0.67 f o r anxiety; and on

LPs the i n te r ra te r cor re la t ions were 0.60 f o r pain and 0.66

f o r anxiety.

I n the in tervent ion procedures.the nan-hypnosis group

were given deep breathing exercises, d i s t rac t ion and prac t ice

sessi on5.

ist traction involved asking the c h i l d t o focus on objects in the room rather than on fantasy .... For example, during a bone marrow aspi rat ion a c h i l d might be ins t ructed t o squeeze h i s mother's hands, t o take a few deep breaths, and t o count the s t r i pes or f lowers on her blouse during the needle insert ion. Pat ients were helped t o no t ice and t o discuss various elements of the treatment room. Sometimes t h i s involved jokes or games, such as the therap is t counting the pat ien t 's f i ngers incorrect ly . The manner i n which these techniques were used was determined by knowledge of the pat ient , fami ly and s i tua t iona l factors. (p. 1033)

The non-hypnotic techniques there-fore emphasized

self-control behaviours and distraction from the painful

procedure. Techniques involving imagery or fantasy were

avoided.

In contrast, during the hypnotic treatment the subjects

were encouraged t o "become increasingly involved in

interesting and pleasant images." Once again, this was

individually tailored t o suit the child and his context.

An exciting or funny story might be told t o a child during a bone marrow aspiration. Gradually the story would be made more vivid by filling it with images and surprises and asking the child questions that called on imagination for answers. For example, the child might be asked t o 'notice the elephant about to squirt water on us' and to describe what he or she 'sees'. During one procedure the therapist helped an adolescent girl to imagine a visit t o a 'boyfriend factory', where she described the 'boyfriend' sRe picked out. She spent the remainder o+ the procedure 'taking her boy+riend on a date.' (p.1033)

The substance of the hypnotic technique consisted of

imagery and the active yse of imagination during the medical

procedures. The subjects in this group were also provided with

practise sessions and encouraged t o breath deeply.

The results showed that the patients rated the BMAs a s

significantly more painful than the LPs. They did not however

report significantly higher levels of anxiety for the BMAs in

comparison t o the LPs.

BMA results. There was a significant decrease in both

pain and anxiety ratings overall. A significant effect between

the treatment techniques and the amount of pain reduction

indicated that hypnosis was more effective than the

non-hypnotic approach. This indicated that while'the

this was less than the reduction produced by the hypnotic

approach. Anxiety however was reduced only by hypnosis: the

non-hypnotic approach produced no significant effect an

an:< i ety . <

LP results. Intervention significantly reduced pain. A

significant effect between the reduced amount of pain and the

treatment techniques indicated that it was hypnosis that

primarily decreased the pain level. There was no significant

pain reduction for the non-hypnotic treatment. Anxiety was

reduced in both treatments, but the hypnotic treatment

demonstrated the greater effect.

In discussing the results, Zeltzer and LeBaron drew

attention to the use of "intense imaginative involvement" as

the distinguishing feature between the hypnotic and

non-hypnotic situations.

The basis for the efficacy of hypnosis may be found in both the nature of hypnosis and the nature of children. Children have a shorter attention span than adults. .. ,After a brief period o-f counting, breathing and noticing objects in the room, most children lose interest and re+ocus their attention on the pain in the procedure(s). (p. 1034)

Children's attention is better held and sustained

through the use of imagination and fantasy, they added. By

creating novel and intriguing situations, children tend to

become more involved and their attention remains directed away

from the painful procedure for longer periods of time.

Like others, Zeltzer and LeBaron drew attention to the

very different therapeutic style required with children.

Unlike in adult hypnotic treatment, speaking in quiet

comforting trance-inducing tones is nat particularly helpful

69

for children in acute pain. By creating vivid, humorous,

exciting and novel stories children readily become involved in

the trance. A helpful recommendation is the observation that

children require "procedural landmarks" Ce. g., "'the needle is

in now" or 'The fluid is dripping'") to relieve them of the

concern for surprises and free them t o return t o their

imaginative involvement.

Zeltzer and LeEaron conclude with these cautions:

"although hypnosis was generally successful in reducing pain

and anxiety, it usually did not eliminate these symptoms

entirely", furthermore, treatment techniques should not b e

applied t o every child, such a5 those children who have

already developed coping skills, a s this can be

counter-pr~ductive Cp.1035). Zeltzer and LeBaron recommend

that future studies examine factors such as hypnotic

susceptibility and previous coping'strategies t o qurther

understand the individual variations that exist in pain

research.

Evaluation of the study ...................... By comparing the effects for hypnotic and non-hypnotic

treatment the authors were able t o partial out behavioural -

factors such as relaxation, and placebo ef-fects such a s

emotional support. Moreover, the two treatments in this study

were clearly separated and therefore improved upon earlier

work (Hilgard LeBaron, 1982). Conclusions about the

effectiveness of hypnosis in reducing pain and anxiety in an

acute pain situations for children and adolescents could thus

70

be v a l i d l y drawn. There was no contro l or attention-placebo

group t o contro l f o r changes over time. However, by tak ing 1

t o 3 baseline observations the researchers reduced random

er ror and thereby increased the re1 i a b i 1 i t y of t h e i r measures.

The implemented treatment methods were creative,

stressing therapis t f l e x i b i l i t y and moving away from the

formal hypnosis model i n which an hypnotic induct ion precedes

any trance experience. The researchers found t ha t t h e i r

subjects were able t o r ap id l y become imaginatively involved i n

v i v i d stor ies. This in tervent ion i s p a r t i c u l a r l y relevant t o

the high stress of the oncology u n i t and surgery room.

A concern t ha t emerges about the non-hypnotic treatment

i s whether i t was s u f f i c i e n t l y competit ive wi th the hypnotic

treatment. The therapis t 's reper to i re i n the d i s t r ac t i on

condi t ion may have been more l i m i t e d than i n the hypnotic

treatment, as i t w a s r e s t r i c t e d t o d i s t rac to rs w i th in the

surgery room.

The authors gave absolute credence t o the pat ien t 's

self-report. This i s t o be commended as i t i s uncommon i n

applied studies. The se l f - repor t scores thus formed the basis

oC the major analysis t o determine treatment effectiveness.

Advocating and demonstrating the effect iveness of

hypnotic and non-hypnotic methods tha t incorporate humour,

responsiveness t o and c reat ive in te rac t ions wi th the c h i l d i n

a h igh ly stressed s i tua t ion , make t h i s study a noted

contr ibut ion t o the emerging f i e l d of ped ia t r i c behavioural

medicine.

The Present Study ---------------- A1 though the treatments of hypnosis and behavioural

methods have been demonstrated a s effective with children aged

6 to 17 years (Zeltzer t3 LeEaron, 19821, the efficacy of these

methods with children aged 3 ta 6 years who have the highest

incidence of leukemia has not been systematically

investigated. The present study undertook to do this, and t o

determine the efficacy of a hypnotic treatment (imaginative

involvement) and a behavioural treatment (distraction) when

compared t o the standard medical practice for the pre-school

and the primary school-aged child.

Rgs~acch-H~es&heges

This study tested the f 01 lowing hypotheses:

1. Psychological interventions of distraction and imaginative

involvement will be more effective in reducing distress, pain,

and anxiety in children undergoing BMAs and LPs, than the

current standard medical practice of providing information and

emotional support,

2. The two psychological treatments, distraction and

imaginative involvement, will be differentially effective in

reducing distress, pain, and anxiety.

3. The effectiveness of the two psychological treatments,

distraction and imaginative involvement, will be

differentially effective for children at different age levels-

4. Hypnotic susceptibility and treatment effectiveness will

be positively related, 'particularly in the imaginative

involvement treatment group.

72

CHAPTER THREE

METHOD

S ubi~~Ls

Fifty-six children (aged 3 to 10 years) with Leukemia,

who attended the Oncology out-patient department of British

Columbia Children's Hospital participated in the present

study. The researcher was introduced t o the child and parents

by the head nurse, or nurse clinician on the family's arrival

in the out-patient clinic. The study was explained t o them in

language that children would be able t o follow:

This is a study looking at how children handle BMAs and LFs. We want t o first observe and understand which parts are difficult and which are easy for each child. After observing the first set of procedures we'll spend some time with you talking about what happened and getting t o know more about you and your experiences here. Some of the children will then continue t o be observed and the others will have others things shown them. We're trying t o find out what we can do that best helps kids manage the BMA so that it doesn't bother them as much. Would it be OK with you if I and my colleaqes were t o watch your BMA today?

Fif ty-nine chi ldren, deemed by the medical sta9f a s

possibly needing help in managing the procedures, were

initially approached t o join the study. The children were

invited t o participate if they found the BMA or LP

distressing. The child's self -report thus served a s the

criterion for inclusion in the study. 0f the 59 children

approached, 3 refused; the parent o+ one patient refused, the

second patient withdrew a-fter baseline observations because

the other parent, who had not been present at baseline was not

in agreement with any form of research, and the final patient

did not want t o participate, although his mother was keen that

73

he par t ic ipate. A l l the remaining 56 chi ldren said they found

the medical procedures t o some degree distressinq.(The consent

from i s contained i n Appendix El.

Forty-eight of the 56 ch i ldren were seen f o r both the

baseline and the f i r s t treatment session. Four subjects d i d

not re turn f o r the procedures during the year of the study; 2

completed treatment: 1 withdrew +ram the study, as the parent

not present during basel ine subsequently rescinded consent; 1

was hospi ta l ized and the remaining procedures were performed

i n the in-pat ient un i t .

O f the 48 ch i ldren seen f o r intervention, 6 were

considered "copers" by the s t a f f because of t h e i r unusual 1 y

calm and co-operative behaviour during the procedures. A l l 6

were male, 3 were aged 6.5 t o 7 years; the other 3 had turned

10 years and were the oldest ch i ldren i n the sample.

Nevertheless, a l l o f the 6 reported some degree of anxiety

p r i o r t o and during the procedures and thus wanted t o

pa r t i c ipa te i n the study.

The mean age of the 48 subjects was 6 years 11 months

(s.d.=24.04 months) w i th a range from 3 years 4 months t o 10

years 3 months. Th i r t y subjects were male: 15 younger subjects

(3 t o &years 11 months), and 15 older (7 t o 10 years).

Eighteen subjects were female: 10 younger and 8 older. The

subjects were predominantly Caucasian; 3 were Asian, and 1 was

Canadian Indian.

Th i r t y of the 48 subjects were seen f a r a second

treatment session. The reduced number was due t o some chi ldren

not requ i r ing fu r ther medical procedures f o r the durat ion of

the study.

At diagnosis the children were assiqned to the CCSG

(Childrens' Cancer Study Group) protocols designed -For the

di+ferent levels of risk. This determined the +requency of

their BMAs and LPs: that is, every 3 months Sor high-risk,

every 4 months for moderate risk, every 6 months for low risk.

These protocol regimens were immediately interrupted i+ the

diagnostic BMA indicated relapse. When that occurred the.

rigurous drug treatment program and monthy BMAs w e r e

reinstated until the disease process was controlled or

remitted. Five children in the sample relapsed during the

year-long research program: one had a successful bane marrow

transplantation, three are still in relapse, and one died.

In the ninth month of the research program the CCSG

brought out a protocol revision, recommending that once

patients had completed the compulsory 3 years of drug

treatment, the BMA should only be performed ahen the

peripheral bload count indicated prablems. Prior ta this,

patients in remission and off drug therapy were given

diagnostic BMAs every 4 months for a further two years to

ensure they maintained a disease-free state for 5 years. Gs a

result of this change, 5 children in the age group 7 to 10

years no longer needed BMAs. All o+ the 5 patients had

experienced one intervention, therefore measures were not

obtained for these patien-ts on the second and final treatment.

75

Sgkz:

Early studies of children and adolescents undergoing

invasive medical procedures (Katz, Kel lerman ?< Siegal , 1980;

Hilgard % LeEaron, 1982) reported sex differences in both

observed and sel+-reparted levels of pain and anxiety, with

females tendinq to show higher levels. More recent research

(Eat%, Kellerman & Siegal, 1982; LeBarmn 8 Zelrer, in press)

has found no sex differences. fis a result, the subject'^ sex

was not included as a variable to be controlled.

4 9 e ~

Age has emerged as a critical variable in the management

of painful situations. Mast of the previous1 y mentioned

studies reported that anxiety is inversely related tu age;

that is, the younger child displays more diffttse verbal and

physical expressions of distress than the older child.

However, the criterion for separating age groups is often not

consistent in these studies. The Katz et al. study (19EQI

divided the sample into thirds (0-8m to 6yrs 4m; 6yrs &m to

9yrs llm: 1Oyrs to 17yrs 9m). Hilgard % LeBaron (1982), with

children aged 6 to 19 years, divided their sample at the age

of 10 yrs, as did LeBargn & Zeltzer (in press). The rationale

was that after 10 years of age, "the self-reported pain and

the observed behavioural indications of pain diverged"

(Hilgard & LeBaron, 1982, p. 431). Jay, Orolins, Elliot &

Caldwell (19831, in their assessment of children's distress,

divided their sample of 42 pediatric cancer patients into 3

age groups (2 to 6 years: 7 to 1 2 years; 1 3 to 20 years): The

76

authors noted that age and stage of cognitive development is

likely t o be associated with the "meaning" children attribute

t o pain, however no further elaboration was given for the

formation of their groups.

The research findings detailed above-and Piagetian

cognitive theory provided the guidelines for determining the

age groups in the present study. According to Piagetian theory

and research in cognitive development (Ginsburg & Opper, 1969)

there are two pre-operational stages of cognitive develapment,

from approximately 2 to 4 years and 4 to 7 years of age. The

concrete operational stage starts at approximatelv 7 years of

age.

Consequently the age groups adopted in this study were 3

years t o 6 years 11 months (the younger group); and 7 years t o

10 years 11 months (the older group). From observations and

pilot work, three years appears t o be the earliest age that

interventions such as imaginative involvement can be applied.

It is also standard medical practise t o give sedation t o

children under three years, thus treatment effects would have

been confounded. None of the children seen in the present

study was given sedation.

Ihe-Settfns

The out-patient department served both oncology and

hematology patients. It i s a relatively small unit for the

patient load it carries and includes the following: a small

waiting area; a large treatment room with beds lining the

t. walls, a small table centrally placed for the children t o play

77

on, a TV, and chairs for parents t o sit if their child is ill

or is having intraveneous ( I V ) therapy, blood transfusions, ar

recovering from procedures. This treatment area led to and

abutted the surgery room. Sound therefore carried over quite

readily from the surgery room into the treatment room.

The BMA and LP procedures and some 1%' inserts are

performed in the surgery room, which was a small room

(approximately 3m by 2m). It contained a treatment table, two

chairs, (one for the physician t o use during the LF, and the

other for the parent) sterile equipment, a surgical table and

a wash-up area. The room was crowded once the child, parent,

researcher, two observers, physician, nurse, and blood

technician were present.

Since space was at a premium, the only available room in

the out-patient area for interviewing the patient and parents,

and for the preparation prior t o intervention was the

isolation room. This tiny room (approx. 2m by 1.5m) served all

the out-patient departments and was used for children

suspected of having an infectious condition or those who

needed isolation for some other reason (egg., being sleepy and

irritable). The room contained a small hospital bed and three

chairs. Permission was granted t o display laminated pictures

on the wall so that a cheery environment could be created.

Child and parent were interviewed in this room, and

preparation sessions prior t o the procedures a5 well a s the

administration of the hypnotic susceptibi 1 ity scale were

carried out in this room.

B.C. Children's Hospital i s the major treatment centre

f o r the e n t i r e province of B r i t i s h Columbia. Consequently i n

many instances pat ien t fami l ies t rave l led long distances f o r

t h e i r appointments and remained overnight i n Vancouver. Tn the

present study a l l of the ch i ldren were accompanied by one or

two parents. and frequent1 y by s ib l ings. (Only the parents

were permitted t o accompany the c h i l d f o r the procedure).

Because of space and management problems, pa t ien ts and t h e i r

fami l ies were encouraged t o wait i n the wai t ing area and not

i n the treatment room.

The c l i n i c performed approximately 30 BMAs per month on

ch i ld ren wi th cancer up t o 1b years o f age. Frequently

procedures were block-booked two or three per day so tha t one

followed another. The outpat ient c l i n i c had approximately 10

chi ldren booked each morning of which 2 or 3 would be seen fo r

a BMA and/or LP. The remainder would have procedures such as

blood work or I V therapy.

The same physician performed a l l BMA and LP procedures.

She was assisted by a head nurse and a p rac t i ca l nurse who was

en l is ted i f the c h i l d needed res t ra in t . The out-patient c l i n i c

was acknowledged t o be a stressed u n i t wi th mu l t i p le demands,

a heavy schedule, and l i m i t e d space.

TWO observers who previously had been ac t ive volunteers

i n the B.C. Children's Hospital were i nv i t ed t o j o i n the

i research program. Both observers were parents of teenage

psychology degree, and the other had t ra ined a5 a nurse. A

t h i r d observer, (a registered nurse no lonqer working) was

recru i ted and b r i e f l y t ra ined as a reserve observer, should

one o# the two fu l l - t ime observers not be avai lable. This

occurred on only three occasions during the year o-f the study.

The two observers were t ra ined d a i l y by the researcher

f o r a s i x week period. Because of space r e s t r i c t i o n s i n the

surgical room, the t h i r d observer could not be included i n

t h i s t r a i n i ng program, and she received approximately w e

week's t ra in ing.

Training f a r the two observers consisted of a general

o r ien ta t ion t o the oncology un i t , the nature and ra t iona le of

the PMA and LP procedures, and the e th ics and requirements of

the research project. They were given relevant psychological

and medical l i t e ra tu re . Following or ientat ion, the observers

were t ra ined on the Procedure Behaviour Rating Scale (Revised)

during actual procedures and videotapes of the procedures. The

videotapes were p a r t i c u l a r l y useful as they permitted

replaying of subt le or ambiguous behaviours thereby increasinq

the observers" perceptiveness and accuracy. The observation of

these procedures was i mmedi ate1 y f 01 lowed by discussion and -

c l a r i f i c a t i o n of terms, protocol, behavioural issues and

personal reactions. Adequate preparation f o r the emotional

stresses and s t r a i ns of observing ch i ldren i n pain was deemed

essential. Support and 'winding down' sessions were f requent ly

held wi th the observers a f t e r d i f f i c u l t sessions, p a r t i c u l a r l y

during the baseline data co l l ec t ion phase.

80

t.tECsSUEES

Three observational measures (0-6 distress, pain, and

anxiety) and two self-report measures (of pain and anxiety)

were used.

Ihe-Prnred~re,8eha~~or-R,at,Cn_~~Sc_aLe_~Ee_vL~~d-L~E~S=EL

The PSRS is an interval checklist, and w a s developed by

Katz, Kellerman and Siegal (1980) to measure the anxiety and

pain behaviour of children aged 8 months to 17 years 9 months

undergoing BHhs. In its revised form the PPHS-R is an interval

check1 i5t of 11 distress behaviaurs over three time intervals

(Katz, 1979).

The PBRS-R was suitable for the present study as it

measures distress behaviour specific to the BMA procedure. It

furthermore included younger children in its sample and

demonstrated high inter-rater reliability.

Analyses of the results of the PEHS behaviour items (by

Katz et dl.) indicated that the scale differentiated between

low and high anxious children, as measured by independent

nurse ratings on a Likert-type scale. Inter-rater reliability

checks were performed using simultaneous independent ratings

by two observers over 22 BMAs for four phases of the

procedure, and yielded the Pearson correlations of r= -94

(phase 11; r = -88 {phase 2 1 ;r = -91 {phase 3) ; r = .92

(phase 4) . The total inter-rater correlation on the PBRS was

-94.

The PBRS-R however, consisted o+ three phases and

differentiated the anesthetic phase from the actual procedure

and thus did not require observations immediate1 y f 01 lowing

the procedure. This enabled an observer to collect self-report

data.

The phases are:

START

Phase 1: Child enters room

Phase 2: Pre-numb sw ab,and loc

FINISH

Clothes are removed from

the site

a1 The needle is withdrawn

anesthetic administered

Phase 3: BMA procedure is done The band-aid is placed

on the cite

Phase 1 represents the anticipatory period, phase 2 the

preparatory period and phase 3 is the procedure itsel+.

There has been some disagreement about what the PBRS

measures. Katz et dl. (1980) referred to the PBRS as a measure

of behavioural anxiety. However, Schachum and Daut ( 1981 1

noted that the PBRS measures bath anxiety and pain and added

that precise theoretical definitions of pain and anxiety would

help distinguish these two constructs. In.their reply Katz,

Kellerman & Siegal f 1981) wrote:

When referring to a,cute clinically noxious situations, it may not be feasible to separate anxiety from pain, since anxiety is the basic af f ective experience that modulated perceived pain.. . From a clinical perspective our focus was on the continuous nature of anxiety throughout the procedure and its relation to the actual noxious stimuli. (p. 470)

In subsequent research Katz et al. correlated self-report

measures of fear and pain with the observational scale and

independent nurse rating, and found further construct I

validation for the PBRS measuring anxiety more strongly than

pain. Schachum and Daut's critique had however moved Katz

(1981) to clarify his stance: "It may have been more correct

to refer to our scale.. ,as a measure of behavioural distress

rather than anxiety.. ..distress being a general t e r m

encompassing behaviours of negative affect including anxiety

fear and pain". Ip. 471)

In the present study, the PERS-R was used as a

comprehensive objective measure o-f distress, which includes

anxiety and pain. The scale may be seen in Appendix C. .

A_n,~Le%~-a_n_d_-Pa_hn_-Jsd_~emen_t-~Fcafhn_q-fjcale

The second observational measure was a 5-point

Likert-type scale, which the attending physician, nurse,

parent and two trained observers independently completed

immediately f ol lowing the procedure.

The Gnxiety scale was divided into 3 judgement phases to

parallel the PBKS-R phases (approach, anesthetic, and

procedure), and scoring ranged from 1 (very little anxiety) to

5 (severe anxiety). The Pain scale was divided into t w o phases

(anesthetic and procedure; there is no pain in the approach to

the treatment room). Scores ranged from 1 (very little pain)

to 5 (severe pain). These two scales are contained in Appendix

%slf=Esesrt,nf,PsLa,-an_rl-Bn_~Lety

pictokid1 scales 09 pain and anxiety (see Appendix E)

were developed +or this study and validated on a non-oncology

hospital sample, The scale consisted of drawings o f a child's

83

face, depicting 5 degrees o+ increasing pain, or of anxiety. A

score of one represented a neutral face showing no pain or no

anxiety, while five was scared far the face depicting "hurting

the most" or "the most scared".

The scales were presented to the child by one observer

once the child had left the surgery roam and was settled in

the treatment room. The child was asked t o point to the face

that showed how much the B M W L P had hurt him or her, or how

scared he or she felt during the BMA/LP. These self-report

scores were obtained in the absence of the experimenter and

medical staff so as t o minimize the child's desire t o please,

and wherever possible, in the temporary absence of the parents

t o avoid contaminating the self-report scores with other

i ssues.

Physiological measures were not used in this study. Some

researchers advocate using physiological measures of anxiety

(e-g., Melamud, Robbins & Graves, 1982). These researchers

maintain that such measures provide a more complete assessment

of anxiety, and bypass the problems o+ subjective judgement by

directly gauging autonomic activity. The measurements most

favoured are heart rate, blood pressure, galvanic skin

response, and el ectrodermal pal mar sweat index . The drawbacks of physiological measures are considerable.

Peripheral physiological measures d o not provide a

straight-f orward index of sympathetic arousal which promote

anxiety responses and the inner experience of apprehension. On

a physiological measure, agreement across many subjects is

frequently poor a s there are individualistic styles o+

,

84

autonomic response lBorkovec, Weerts, & Bernstein, 1977).

Furthermore, there is no correlation between speci+ic

physi 01 ogical responses and particular behavi oural responses.

Physiological instruments may equally be tapping emotions of

anger, resentment or joy rather than anxiety. Finally, the

instruments used for physiological measurements are an

intrusion in a clinical setting and can distract, disturb and

add stress to the patients and medical staff in a procedure

that is already stressful. For the above reasons, as wel.1 as

the considered judgement that physiological measures would not

add sufficient information to outweigh the drawbacks,

physiological measures were not used in this study.

shortened for an easy administration of 20 minutes within a

clinical setting. It consists of six discrete items that can

be achieved during hypnosis: the ability to achieve these

items yields an index of the child's responsivity to hypnotic

suggestion <See Appendix F).

The SHCS-C was administered to obtain an independent

measure of the subjects' capacity for trance and imaginative

involvement. In all cases administration was done after the

procedures. There was insufficient time before the procedures

and anticipatory anxiety may have interfered with the child's

involvement in the hypnotic exercises. An attempt was made to

give the scale at the end of the final treatment session, so

as not t o i n t e r f e re w i th the d i f f e ren t psychological

treatments.

The scale w a s administered t o 30 children. Scores were

not obtained-for 18 of the 48 treatment subjects f o r the

fo l lowing reasons: 6 subjects were under the age of 4 years

which was the minimum age f o r the scale; 5 subjects whose CCSG

protocols were changed d id not re turn f o r t h e i r f i n a l

treatment; 3 subjects were not co-operative (one was ill, the

second depressed and withdrawn, and the t h i r d wanted t o .p l ay

her own game). Four other protocols were not completed because

of scheduling d i f f i c u l t i e s . Typica l ly a f t e r each procedure the

physician asked t o examine the c h i l d and thereafter e i the r t h e

researcher was involved wi th the next patient, or parents and

c h i l d had t o leave.

Procsdure

Pr io r t o the f i r s t in tervent ion the 48 subjects were

randomly assigned t o one of three treatment groups: Group I ,

Standard medical procedure; Group I I, Distract ion: Group I I I,

Imaginative involvement.

Gcnu,e-L~ Standa~d-!ed,hc_a_L~P,c~ct,ic_e_~1C_o_~~~~L~~

The chi ldren received the current standard medical

p rac t ice provided f o r ch i ldren undergoing EMAs & LPs. This was

the contro l condition. It included providing information

concerning the procedure when the c h i l d entered the surgery

room and during the procedure. If: the c h i l d asked about,. or

wanted t o see some of the equipment, such as needles, sponges,

or the j e t (i.e., the l oca l anesthetic t ha t operates under

86

i t would be used. Even i C requested, the actual needles were

r a r e l y shown, except when the physician and nurse f e l t i t

c l i n i c a l l y appropriate.

During the procedure the c h i l d was given information

about what would occur. For example, " Do you remember we wash

y a w back three times? Here i s number one...". Sensory

information was commonly given i n standard medical pract ise,

f o r example: "Now t h i s might hu r t f o r a minute, but i t ' l l be

over soon". The ch i l d ' s questions during the procedure were

always answered. For example, " I s the needle out?" "No, but

i t " l 1 soon be out. You3re doing well". Reassurance and support

was provided verbal ly and non-verbally t a the c h i l d should she

or he become distressed. For example, the nurse asked "Would

you l i k e t o hold my hand?" Nonverbal cantact was deployed less

frequently, although on occasion the nurse would stroke the

ch i l d ' s forehead, whi le she re i te ra ted the request t o l i e

s t i l l .

On occasion the physician, nurse or parent asked

questions or ta lked general ly about such top ics as the journey

t o hospi ta l , how school w a s going or what the c h i l d planned t o

do afterwards. Typical ly, t h i s in te rac t ion occurred i n -

'dead-spaces' i n the procedure, when the physician was wait ing

fo r the anesthetic t o take e f f ec t and nothing e lse was

happening. The leve l of involvement between c h i l d and medical

staf+ i n these instances w a s general ly low-keyed and kindly.

During the procedure the s t a f f a lso f requent ly ta lked amongst

themselves. The standard medical p rac t ise d i d not include the

ac t ive use of toys ar other child-centered techniques such as

r e l a t i n g in te res t ing or amusing tales.

These procedures took place with the experimenter present

in the room, so as t o contro l f o r experimenter presence across

the three groups. The experimenter's involvment wi th the c h i l d

was peripheral; she sat as an observer a t the back of the room

and d i d not take pa r t i n the process.

There were two phases i n the treatment conditions, the

preparation and the medical phase.

ereearakios

Group I 1 and Group I11 subjects were given a preparation

session of 10 t o 20 minutes, during which the c h i l d was

fami l ia r ized and t ra ined i n the treatment method. This

occurred immediately p r i o r t o t h e i r medical procedures. Since

the parents were encouraged t o accompany the c h i l d i n t o the

procedure, the parents wherever possible, were also included

i n the preparation period. There was no preparation period fo r

Group I , as t h i s group rep l ica ted standard medical pract ice.

Pregaration phase f o r Groue 11: D is t rac t ion --- -----_-- -__---------- -_-_--_--___---- The c h i l d was shown toys, puppets, pop-up books, and

bubbles, and experimenter and c h i l d explored them together.

The c h i l d was encouraged t o choose which items she or he

wanted i n the treatment room "so t ha t we can t a l k t a them" or

1) f i n d what e lse i s hidden i n the haunted house book whi le the

%MA or LP gets done".

The younger group were also shown bubble blowing; which

they practised. They were encouraged and received pos i t i ve

reinforcement for big breaths and counting the bubbles. They

were told: ' *1 f you feel something that bothers you, all you

need to do is...take a big breath and blow the bubbles".

The older group were shown how deep breaths induced

relaxaticm. They were tald: "If anything bothers you, all vou

need to do is take a deep breath and blow. You can do that by

yourself whenever- you want. Its easy, all you do is deep

breath in and blow it out".

The intention in the preparation period was to minimize

the child's anticipatory anxiety by playing with pleasant,

interesting objects and by practising bubble blowing or deep

breathing.

Medical Phase for G r o u ~ XI: Distraction ...................... ---------------- This group received techniques which aimed at active

distraction; that is, shifting and actively directing the

child's attention throughout the medical procedure. The

therapeutic intention was ta maintain a l o w level of anxiety

and to diminish pain perception by shifting the child's

attention away from the painful stimulus and onto competing,

interesting objects and people in the surgery raom.

Techniques used included:

1. Introducing a variety o+ physical objects such as hand

puppets, squeaky toys, and pop-up books, to shift attention in

a meaningful manner. The colourful pop-up books were

particularly popular as they provided surprises and an

opportunity for questions, comments, and humour.

2. Asking distracting questions, such as "How many fingers

has Dad got..13?..No? Let's count them!" The experimenter

89

p lay fu l l y counted incorrect ly , encouraging the c h i l d t o

correct her.

3. Requiring the c h i l d t o carry out d i s t rac t ing physical

exercises such as blowing bubbles, squeezing Mom's hands or

simply breathing i n and out together wi th the therapist. This

was used p a r t i c u l a r l y when the c h i l d was i n pain. Blowing

bubbles was very useful t o i n te r rup t cry ing and s h i f t the

ch i 1d"s a t ten t ion from physical concerns t o f 01 lowing the

bubbles v i sua l l y u n t i l they landed.

4. Using humour as a d is t ract ion; t e l l i n g jokes, asking f o r

jokes and gent ly teasing the other s t a f f members.

The focus i n t h i s treatment was external, on the "here

and now" of people and objects i n the surgery room. The

therapeutic goal was t o s h i f t the ch i l d ' s a t ten t ion away from

the pa in fu l st imulus onto a va r ie ty of d i s t rac t ing s t i m u l i , and t o maintain an intense leve l o f i n te rac t ion between c h i l d

and therapis t during the procedure. The experimenter l e d the

in te rac t ion wi th the ch i ld , however the nurse and physician

sometimes in te r jec ted comments or questions, and t h i s was

allowed as i t tended t o enhance the d i s t rac t ion condition.

~reearatLsn,snszLns-for-CroueeIXI~Ima~Ln~~~xs

Invol vemen t ----------- An easy p l ay fu l i n te rac t ion was created wi th the c h i l d i n

which a number of i n d i r e c t suggestions were given t o encaurage

the establishment of hynot ic - l i ke behaviours, ( e . g . , Who i s .

your favour i te guy on Sesame

I and t a l k wi th him?" or "Gee,

s t ree t? Would you 1 i k e t o v i s i t

wouldn't i t be a n ice surpr ise if

90

today before you knew it, the BMA was over. I wouldn't be

surprised, 'cause one of the ways time goes really fast is

when you're swimming ..." I. The stories or adventures were individually tailored

using content that was personally relevant to each child. The

stories were elaborated upon so that they became vivid,

pleasant experiences. The child was then asked if he or she

would like to, for example, "go swimming during the %MA so

that before you know it, the band-aid is on and it's time to

go to MacDonalds".

Children were encouraged to choose where they wanted to

go and what they wanted to do in their imaginations.

Ego-strengthening suggestions were also given and the child

practiced one or some of the techniques, if possible, during a

trance state before the procedure.

A popular hypnotic techniques for pain re1 ief with

children (it has also been used with adults) is the "switch"

technique. A n adaptation of Pearson's version of this

technique (Pearson, 1982I, was used in this study. This

technique provides direct suggestions for hypnoanesthesia for

selected parts of the body, through the notion of "on or off"

switches that control pain messages. Details of the switch

technique as well as an elaboration of the therapeutic process

combining the different hypnotic techniques during the medical

procedure, are described in Appendix A.

This group received an informal hypnotic technique (i.e.,

a formal hypnotic induction was not given in the surgery

room). The technique aimed at creating an imaginative

experience that would lead to a different interpretation of

the noxious experience. Since children frequently and easily

shift in and out of trance, a "weaving" technique was created.

This technique consisted of relating a f avouri te story or

adventure that the child could imaginatively enter, and then

interweaving the procedural information that the child needed.

Indirect suggestions or direct suggestions for com+ort and

coping were also spontanteously woven into the story line.

Imaginative involvement, with its naturalistic weaving of

story, specific hypnotic suggestions and information was

standard across all children assigned to this condition.

However, there was considerable variation in content because

of age and sex differences, and the recognized importance of

individually tailoring the imaginative involvement to suit

each child.

For the imaginative involvement condition, the

experimenter was generally the only adult to speak during the

medical procedure. This enabled the child to maintain

concentration and absorption in the story or fantasy.

Information about the procedure could also be looped into the

story, but this was only done if the child became anxious

without it, or if she or he had asked to know certain parts of

the procedure, Once the information was given, the fantasy was

revived and the child was encouraged to re-enter it. During

the more painful parts of the procedure the fantasy was

intensified t o increase the possibility that this alternate

92

experience would be competitive with the pain or discomfort.

The f ol lowing types of associ ational and di ssociational

suggestions were used:

1. Suggestions for time-distortion, for example: "Wouldn't

it be nice t o have the BMA and not pay any attention t o it and

then be surprised that it's nearly finished... ?

2. Suggestions for analgesia, for example: "See your purple

pain switch that connects t o your back? Turn it down..down..so

that you know something is happening but it doesn't bother

you.. " . 3 , Suggestions far body dissociation, for example: "It's a

surprise! Your space craft easily just lifts off the ground,

and as you go up you can see everything from high, high in the

sky. You can see your friends playing, you can see us from

high up ..., and where do you want t o take your space craft now? 4. Suggestions for alteration or modification of sensation.

Far example, i-F the child experienced the local anesthetic as

a sting:"That sting i s beginning t o become a tingle and I'm

not sure how fast it's happening. ..maybe when I count t o 5 , . .

one, two, a tingling nice feeling.,maybe you're feeling it

more on your side..tell me where has the tingling feeling

started?.. where are you feeling that tingle most?

The emphasis in this treatment condition was t o absorb

the child's attention through an involving story or fantasy

which would modify the experience so that the child had a

different interpretation of it and some relief from pain and

anxiety. The focus was on facilitating the child's imaginal

processes, thus the focus in this condition was internal.

P~fference~-b~tweee-the~tw~~treatme~~~

The treatment groups were designed t o be distinct and

non-overlapping, in order t o allow findings t o be drawn that

compare truly different methods.

Distraction had an external orientation. The child's

attention was drawn t o physical objects and people. The

therapeutic style was lively and actively paced, shifting the

child's attention from one object t o another, interrupting

with questions and distracting the child's attention AWAY from

the painful stimulus. There was no attempt to -focus the

child's thoughts on internal imagery or draw the child into

trance, although it is recognized that distraction used in

other ways can induce an hypnotic trance. However no

suggestions for the alteration of, or dissociation -From the

experience were given in this condition. The child remained in

the "here and now" of the surgery room. Finally, the other

staff members in the roam were also involved as part of the

distraction process.

In contrast, imaginative involvement had an internal

orientation. The process was entirely an imaginal one. No

physical objects were used and the child was encauraged t o use

imagination t o create a different interpretation of the

experience. The therapeutic interaction between child and

therapist was quiet, intense and continuous, narrowing and

absorbing the child's attention into the vivid details o-F the

story or adventure. Sometimes the child shifted in and out of

the fantasy and since this was expected, an informal weaving

94

technique tha t accommodated f l e x i b l y t o these changes was

used. Suggestions f o r a1 te ra t ion of experience, self-control

techniques such a= the switch technique ar dissociat ion were

also interwoven, as the intenti 'on was t o trans+arm the pain+ul

experience. F ina l ly , during the procedure the primary

interpersonal i n te rac t ian w a s between therapis t and ch i ld .

Several months a f t e r the f i r s t treatment session, 30

subject5 returned f a r a fu r ther set of medical procedur.es. The

subjects assigned t o t h e two treatment condit ions were once

again given preparation sessians that, where possible, b u i l t

upon t h e i r previous experience. The techniques were once again

rehearsed and the ch i ldren were encouraged t o use them during

the medical procedures.

Design ---- A repeated measures design was employed wi th two

between-subject factors, Treatment and age. Repeated measures

were obtained on the subjects a t three times i n the.caurse of

the study: baseline, f i r s t in tervent ion and second

intervention, The dependent mea5ures were the PBRS-R scores,

the Judgement Ratings f a r Pain and f o r Anxiety given by the 5

raters, and the Self-report Pain and hnxiety scores.

CHAPTER FOUR

RESULTS

The psychological methods of d i s t r ac t i on and imaginative

involvement were appl ied t o BMAs and LPs. Since the %MA i s the

more pa in fu l and f requent ly the more d is t ress ing of the two

procedures, primary considerat ion w i l l be given t o the EMA

resu l ts . Following that , t he LP r e s u l t s w i l l be considered.

The means and standard dev ia t ions of the dependent measures

f o r both procedures are recorded i n Appendix G t o K. ,

For the purposes o f analysis, i t i s convenient t o

consider the data as two sets: Data Set A consists of t he

scores on the dependent var iab les f o r 48 subjects a t basel ine

and the f i r s t in te rvent ion and Data Set B consis ts o-f the

scores f o r 30 subjects a t t he f i r s t and second intervent ions.

SesuL&~,fmm,&he,BMA-P~a~ed,ure

The PBRS-R scores were summed across the two r a t e r s and

subjected t o an exploratory analysis. Dot p l o t s were

constructed, as shown i n Figure 1 ( f o r , t h e younger ch i ldren)

and Figure 2 ( f o r the older ch i ldren) . From the p l o t s it

seemed t ha t a t baseline, the cont ro l group d i f f e r e d from the

two treatment groups. For bpth age groups, the cont ro l groups

appeared t o have the lowest l e ve l s of d istress, t he

d i s t r ac t i on group had the highest, and the imaginal

involvement group was i n the middle of the two other groups.

Possible reasons f o r t h i s w i l l be discussed i n chapter 5.

The la rge ind i v idua l d i f ferences between ch i ld ren on the

PBRS-R basel ine should a lso be noted. Each group has .

CONTROL IMAGINATIVE INVOLVEMENT

FIGURE 1: Dot Rlot of the Younger Children's PBRS-P scores

Summed f o r the two ~ b s e r v e r s a t Basel i .ne (B) , F i r s t (1) and second Intervention (2)

t

CONTROL ' DISTRACTION IMAGINATIVE INVOLVEMENT

First (1) and Second Interventiun (2)

substantial standard deviations (See Appendix G far mean and

standard deviations). The greatest variability existed within

the young age groups in which the mean oS the two rater's.

standard deviations were indicated by 6.83, 5.03, 6.54, +or

control, distraction and imaginative invalvement respective1 y .

The older groups also showed considerable vari abi 1 i ty, with

the rater2s mean standard deviations ranging from 5.10

(control group) to 5.71 (imaginative involvement).

For both Data Set A and E, the means af the younqer

children on the PBRS-R scores were higher across all seszions

than the means of the alder children. However, as shewn in

the next section, this difference was found t~ be not

statistically signi-ficant. There also seemed to be an overall

reductian in the PBRS-R means from baseline ta first

intervention and then to second intervention, which suggests a

general reduction of displ dyed distress over the sessions.

Distrasn

ZZBESZB

Reliability checks on the PBRS-R scores using

simultaneous independent rating by the two trained observers

were calculated for 36 of the 56 baseline BMAs, by using

Pearson Product Moment correlation. The Pearson correlatian

for the combined scores across the 3 phases was r=.98. The

.Pearson correlation for each of the three phases of the PBRS-R

. was as f a1 lows: approach, r=. 94: anesthetic, r=. 40; pracedure

r=. 95.

To control for individual differences at baseline an

,

99

analysis of covariance was used. A repeated measures analysis

of covariance was performed using the Data Set A scores, in

which baseline scores served a= the covariate #or t h e first

intervention scores, The two between-subject S a c t w s were

Group, with three f evels (control , distrsctian and imaginative

involvement) and Age, with two levels !yaunq: 3 to & years 1 1

months, and old: 7 to 10 years) The rater5 were the

within-subject factor. The results shown in Table 1, indicated

a Group by Age interaction at p=.06 but no ather signif.ics.nt

interactions or main effects. A high1 y significant regression

on the covariate was also found. This result was repeatedly

obtained in all the analyses reported in this chapter.

The Group by Age interaction is shown in Figure 3.

This interaction prompted post-hoc analyses on the adjusted

cell means to determine where the significant effects lay.

There were no significant group effects for the older age

group. For the younger group, imaginal invol vernent yi el ded

significantly lower distress scores than either the control

group (F=4.69, p<.05) or the distraction group (F=5. 23,

p<.OS).

This indicates that imaginative involvement for the

young children appeared to be the only treatment to

significantly reduce distress scores within the first

treatment session, as compared to the control and distraction

groups. Distraction however, showed significantly different

e+fects for the two age groups; the older group showed

significantly less distress than the younger group at first

distraction intervention (F=4.82, p<.OS).

A g e ( A 1 3.78 1 3.78 0.15 -70 G X A 151.50 75.75 3. 1 0 .06 - Easel ine 759.27 1 759-27 31 -07 .00 (Covari ate) Error TOOL. 83 41

Haters (R) 0.38 1 0.38 0-23 . &4 R X G 5. 71 2 2.86 1.69 -20 R X A 0.08 1. [:I . t2B 0.05 .83 R X G X A 0.57 2 r:, -29 0.17 .86 Fasel i ne 0.01 1 0 . 0 1 0.01 -94 Error 69.45 41 1.69

Dependent=First Intervention

\ \

\

\ \

Older , \ \

KEY - Younger Group

- - - - - * Older Group

CONTROL DISTRACTION IMAGINATIVE

INVOLVEMENT

FIGURE 3: i n t e r a c t i o n of Group and Qge on

Distress Scores (PBRS-Rl

A r e p e a t e d measures a n a l y s i s of c o v a r i a n c e of t h e

PBRS-R s c o r e s i n D a t a S e t E ( t h e f i r s t and second F n t s r v e n t ~ a n

s e s s i o n s w i t h b a s e l i n e as t h e c o v a r i a t e ) , o n l y r e v e a l e d a

s i g n i f i c a n t main e f f e c t +or S e s s i o n (F=5.24; p = . 0 3 ) . T h e

summary d e t a i l s are g i v e n i n T a b l e 2. S i n c e t h e r e w a s n o

i n t e r a c t i o n e f f e c t of S e s s i o n , Group and A g e , t h i s i n d i c a t e s

t h a t a l l g r o u p s showed t h e same r e d u c t i o n of p a i n f rom the

f i r s t i n t e r v e n t i o n t o t h e s e c o n d i n t e r v e n t i o n .

Two i n s t r u m e n t s measured p a i n : the + i v e - p o i n t

judgement r a t i n g s (by n u r s e , d o c t o r , p a r e n t , raterl , and

rate^-21, and t h e c h i l d ' s s e l + - r e p o r t on p a i n .

&d~ement-Bati~qz

P a i n scores w e r e c r e a t e d by summing t h e two p a i n

scores f rom t h e a n e s t h e t i c and p r o c e d u r e phases for each

rater. T h e r e w e r e r e a s o n a b l y h i q h c a r r e l a t i o n s be tween t h e 5

raters (see Appendix H I . C o r r e l a t i a n s r a n g e d f rom r=.45

between rater2 and p a r e n t , t o r2.34 between n u r s e and p a r e n t .

Rater2 had c o n s i s t e n t l y l o w e r c o r r e l a t i o n s which s u g g e s t s t h a t -

s h e may h a v e been b e h a v i n g somewhat d i f f e r e n t l y f rom t h e o t h e r

raters. T h i s w a s s u b s t a n t i a t e d by a p r i n c i p a l component

a n a l y s i s i n which t h e 4 raters l o a d e d on t h e S i r s t component

. which a c c o u n t e d +or 61% of the v a r i a n c e . R a t e r 2 l o a d e d on t h e

s e c o n d component which a c c o u n t e d for 18% of t h e v a r i a n c e .

Raters w e r e also i n c l u d e d as a w i t h i n - s u b j e c t fac tor i n t h e

a n a l y s i s of c o v a r i a n c e , as shown i n T a b l e 3. The h i g h l y

Table 2 PERS-R Anrova far First and Second 1nterventim-i ............................................... Source Sum of d f Mean t P

Squares Squaro

Group (6) 54.82 Age ( A ) 122.36 G X F , 415.25 Basel i ne 602.58 (Covari ate) Errar 913.34

Sessions(S) 66.01 S X G 22.77 S X A 0.94 S ' X G X A 14.94 Error 302.25

R a t e r s (R) 1.38 1 1.38 0.89 0.36 R X t 8.91 2 4.26 2.73 0.09 R X A 0.43 1 0.43 0.27 0.61 R X G X A 0.54 L 0.27 0.17 0.84 C)

Basel i ne 1.70 1 - 1.70 1.09 0..~1 (Covariate) Error 35.80 23 1.56

S X R 0.99 1 0;09 0.11 0.74 S X R X G 4.80 .& 2.40 2.98 0.07 +-l

S X R X A 1.09 1 1.09 1.35 0.26 SXRXGXA 0.90 2 0.45 0.56 0.59 Error 19.33 24 0.81

Group 43.69 L . i:S.i>6 - 21.85 - Aq@ 3.61 1 3.61 8. 5 !. (3. 48 6 X FI 44.91 3 22.4L 3. 17 0.05 Pasel i ne 78.67 1 75.67 11.12 0.00 Error 3"' ,/d.$S 39 7 . (37 Haters 37.19 4 9. 3:) 8.31 O.QC)(S R X G 25.24 8 3.15 2.82 0.01 R X E ) 3.41 4 0.85 0.76 0.55 R X A X G 2.51 8 0.31 0.28 0.97 Baseline 3.04 1 3.04 2.72 0.10 o r 177.87 159 1-12

165

signi-ficant rater effect con+irmed that the raters also

differed in terms of their mean ratings.

In studying Data Set A {baseline t~ Treatment 11, the

repeated measures ANCOVA showed a significant Group by Age

interaction, which was subjected to post-hoc analysis o+ t h e

adjusted cell means. Far the older group, the distraction

group was rated to be in significantly less pain than the

control group, (F=5.26, p<.051, as was the imaginative

involvement group, (F=4.76, p<.05). The interactian between

Group and Age is displayed in Figure 4. This graph appears to

parallel the pattern obtained in Figure 3 on the Distress

data. and indicates the differential treatment effects on pain

for the two age groups at the first intervention.

The younger group did not show signi4icant treatment

effects when the'combined treatment groups were compared to

the control, however, a comparison between distraction and

imaginal involvement yielded significant 1 y 1 ower judged pain

scores for imaginative involvement IF=6.95, p<.05). Comparing

subjects across age, distraction was signiiicantly more

beneficial in reducing judged pain for the ~ l d e r age group

than for the ,younger group (F=6.3&, p<.05).

A repeated measures analysis of covariance 09 the

Judged Pain scores in Data Set B was performed to determine if

changes occurred between the first and the second intervention

on judged pain. The results are shown in Table 4.

, A siqnif icant main effect for Age was found. The older

group was judged by all raters to be in less pain than the b

younger group across both intervention sessions. There was

\ Older ,

Covar i ate=Basel i ne

Dependent=First Interventi~n

KEY - Younger Group

* - - - -4Older Group

INVOLVEMENT

FIGURE 4: Interaction o-f Group and Age on

Judged Pain at First Intervention

Group 10.88 2 5.44 (3.56 0.58 Age 41.91 1 41.91 4.23 0.05 G X A 26.98 2 13.49 1.38 0.27 Basel i ne 57.30 1 57.30 5.et 0.03 Er ro r 195.66 20 9.78

Sessi ons 23.96 I 23.96 4.08 (3.06 S X G 33.60 2 16. St:, 2.86 0.08 S X A 0.24 1 0.24 0.04 0.84 S X CI X G 12-41 m

L 6.21 1.06 0.37 Err or 123.23 21 5.87

Raters 32.20 4 8.05 8.34 0.0(3 R X G 35.40 8 4.43 4.58 0.(:10 H X A 6.14 4 1.54 1.59 0.18 R X G X A 3.56 8 0.44 0.46 0.58 Basel i ne 3.58 1 3.58 3.71 (?.06 Er ro r 80.24 83 0.97

S X R 0.99 4 0.25 0.24 0.92 S X R X G 2.91 8 13. 36 0.35 0.94 S X R X A 8.60 4 L. 15 2.08 0.09 r\

SXRXGXA 10.00 8 1.25 1-21 0.30 Error 86.81 84 1.03

also a reduction in rated pain from the first to the second

intervention across all the groups. A main effect for Sessions

h a s emerged previously in Data Set B for FERS-R, and appears

to corroborate the finding that with an increase o-F sessions

all of the groups showed a reduction. A highly significant

effect +or raters emerged, as previously discussed.

SeLfxSeeorLeaLs

Four subjects in the younger age group did nat.give

sel*-report scores; two were below four years of age and did

not appear to comprehend adequately the instructions, and the

remaining two were too distressed following the procedure to

respond to the instrument.

The Dot plots (see Figure 5) suggested that f a r t h e

younger children at baseline, lower pain scores were reuorted

by the control group than the two treatment groups. However,

this disparity between the groups does not appear to be

evident for the older children. The plots for the younger

children shaw that the control group began with l o w

self-report scores, showed little change at first

intervention, then dropped and reduced in variability at

second intervention. In the distraction group the scores were

higher than the control scores at baseline. At first

intervention there was reduced variablity, and the scores

dropped at the second intervention. Imaginative involvement

demonstrated a high level af scores similar to the distraction

group at baseline, then reduced at first intervention and

appeared to drop further at the second intervention,

However, an analysis of covariance of the self -report

pain scores of 44 subjects in Data Set A produced results that

were not statistically significant. To determine whether there

were any changes on the second intervention, a repeated

measures analysis of covariance was per+ormed in Data Set B.

Of the 30 subjects at the second interventian, 3 of the

subjects mentioned above were excluded from the analysis, as

they did not have baseline scores. The results are found in

Table S, and confirmed a main effect for the intervention

sessions. The children reported pain levels at the second

intervention which were significantly lower than those

reported at the first intervention.

Two instruments measured anxiety: the five-point

judgement ratings (by-nurse, doctor, parent, rateri, and

rate^-21, and the child's self-report on anxiety.

Judse,m,nst,Satknss

A composite anxiety score was created by summing the

three scores for the approach, anesthetic and procedure

periods together, A correlation matrix (Appendix I ) revealed

high correlation coe-fficients that ranged from a low of r=.72

for rater2 and parent to a high of rZ.90 for doctor and

parent, and for doctor and raterl. Once again the scores for

rater2 appeared to be inconsistent with the other raters on

this measure. This was confirmed by a principal components

analysis in which the four raters loaded on the' first

component and accounted for 86 % o-f the variance, whereas

Source Sum of df Maan F P S q u a r e s S q u a r e s

................................................ G r o u p 1.24 2 (3.62 0.58 0.57 Age 0.58 1 0.58 0.54 C3.47 G X A 1.76 r~ 0.88 0.82 0.45 - Basel ine 12.46 1 12.4& 11,bZ 0.00 E r r o r 21.46 CI 10 1 .0?

Sessions 4.41 1 4.41 8.32 0.01 S X G 0.36 i. 0.18 0.34 0.72 CI

S X A 0.33 1 0 . -33 0 . b Z 0.44 S X G X A 1.54 CI

1 0.77 1.45 0.26 E r r o r 1 1 . 1 3 2 1 0.53

rater2 loaded on the second component and accounted for 13% af

the variance.

Raters were also treated as a within-subject fsctor in

the analysis o-f covariance. Table 6 shows' the results for the

composite Anxiety scores. The high1 y significant rater ef Sect

confirmed that the raters also differed in terms of their mean

ratings.

For Data Set A, a repeatyed measures ANCOVA shawed

significant Group by Age interaction effects. The differential

treatment effects for each age are illustrated in Fiqure 6.

Far the older age group, post-hoc analyses revealed that the

distraction group was judged to be signif icantly less anxious

at the first intervention than the control group (F=5.?3,

p<. Of;), as' was the imaginative involvement group (F=4.?4,

p.:. 05) . For the younger group, the two treatments were found

to differ significantly from one another. The imaginal

involvement group was judged to be significantly less anxious

than the distraction group (F=b.US, p<.05). However for the .

younger group, the two treatments did not statistical 1 y diSf er

from the control. Compared across the age,groups the

distraction treatment had differential e#-fects: the older

group was judged significantly less anxious than the yaung age

group in the distraction condition (F~5.9, p<.05) . To determine the effects on the judged anx,iety scores

between the first and the second intervention, a repeated

measures analysis oT covariance was per#ormed on Data Set B. ,

The results contained in Table 7, show a significant main

Squares Squares

Group 112.18 L CI 56.09 CI &.53 i:~-09 A g e 3-06 1 3, (:I&, 0.14 0.71 G X A 161.28 cI L 80.44 -22.e.23 0.04 ,-

B a s e l i ne 589.73 1 589.73 25.5% 0.00 E r r o r 865.41 39 -.-I LL. 19

Raters 40.74 4 10. 19 3.84 0.01 R X G 25-54 S 3.19 - 1.20 0.30 R X Cl 14-91 4 a.73 1.41 0.23 R X A X G 20.07 8 2.51 0.95 0.48 Basel i ne 5.60 I 5.61 CI .L. 12 0.15 E r r o r 421.43 159 2.65

b:: E'f' --- c--.----. ='iounger Group e - - =t2Ldsr Group

CONTROL DISTRACTION IMAGINATIVE

INVOLVEMENT +-- ----.

FIGURE 6: Interaction of Group and Age on

Judqed Anxiety at First Intervention

Table ------- 7 ANCoVA of A n x i ety Rating 0-F Fi r5t PC S e c ~ n d I n t e ~ v e n t i ~ n ~ Source Sum of df Mean F P

Squares Squares

Group 68.77 Age 158.78 G X A 68-56 Baseline 321.05 Error 643.70

Sessi on 34.15 S X G 37.92 S X A 3.70 S X A X G 31.50 Error 358.40

Raters 51.85 R X G 27.19 R X A 9.61 R X G X A 7.59 Pasel i ne 4.58 Error 262.20

S X R 3.89 S X R X G 16.70 S X R X A 21.25 SXRXGXA 17-85 Error 203.10

effect for Age, indicating that the older group w a s

significantly lower on their observed levels of anxiety than

the younger group.

SeLf~Rsearf-An~Letr

Dot plots of the self-report anxiety scores (see

Figure 7) suggested a reduction in self-report anxiety across

the three sessions for distraction and imaginative involvement

for both age groups, and for the younger control group. The

older control group appeared to increase anxiety levels at the

first intervention, which were reduced at the second

intervention session. Once again, the younger control group

appeared to have lower anxiety self-report scores at baseline

than both the treatment groups. This disparity also was

evident in the older group.

An analysis of covariance of the self -report anxiety

scores was carried out in Data Set A. However, no significant

main effects or interaction effects were found.

When the self-report anxiety scores in Data Set 8 were

analysed in a repeated measures analysis of covariance, a

significant main effect across the two intervention sessions

emerged, as shown in Table 8. This indicated a reduction in

self-report anxiety +or all the groups from first to second

intervention. The main ef+ect for Sessions has been

corroborated by four of the five dependent measures in this

study.

Source Sum of d f Mean F P Squares Squares

Group 2.28 2 1.14 1.16 0.33 A g e 3.80 1 3.80 3.86 0.06 G X A 5.84 1 2.92 2.97 0.07 .7

Base1 ine 1.52 1 1.52 1.55 0.23 Error 19-65 20 0.98

Session 6.08 1 6 . 08 11.22 0.00 S X G 2.44 1 1.22 2.25 0.13 S X A 0.08 1 0.08 8.14 0.71 SXGX6 0.22 - 3 (3.11 0.20 0.52 E r r o r 11.38 21 0.54

r 119

To see whether the measures captured a s im i l a r domain

of behaviour , cor re la t ion matrices were calculated f o r paxn

and +or anxiety t o determine the v a l i d i t y and

in te r re la t ionsh ip of a1 1 the pain and anxiety measures. Since

PBRS-R i s a measure of d i s t ress and incarporates both pain and

anxiety, the PERS-R scores were included on both matrices.

The moderately high cor re la t ions between the pain

measures , ranging from r=.50 (between PBRS-R and Rater21 t o

r=.79 (between PBRS-H and Rater l ) , coqfirmed tha t the PBRS-R

measured s im i la r behaviours t o what the pain measures

captured, De ta i l s may be seen i n Appendix H.

Ggrrelations,Ps$w~en_~kh,~!~An_x_het,~~M~a~~~ce~-~~-E~s~Lin_~

Correlat ions between anxiety measures were s l i g h t l y

higher than those on pain. The co r re la t ion of the PBHS-R

scores wi th the s i x other measures ranged from a low o f r=.71

(Rater21 t o a high of r=.88 (Nurse). I t i s i n te res t ing t o note

the s im i l a r scores f o r nurse, doctor. and parent. The

co r re la t ion matrix i s contained i n Appendix I.

explored as previous research had emphasized the r e l a t i onship

o f age and d is t ress (Katz e t e1.,198Q; LeBaron & Zeltzer, i n

press). A Pearson Product Moment co r re la t ion o f r=--45 w a s ,

found a t baseline, r=--47 a t f i r s t intervent ion, and r=-063 a t

second intervent ion. The smallest co r re la t ion a t basel ine was

s ign i+ icant (F-12.3; p<.Ol). The negative re la t ionsh ip

120

between distress and age indicates that younger children

exhibit their distress mQre openly than older children.

The self -report measures o-f pain and anxiety have .a

weak correlation with age (r=--24 with self-report pain, and

r=-.34 for self-report anxiety). The poor correlation between

age and self-report is understandable as the subjective

experience o+ pain or anxiety is not age-dependent. This is in

contrakt to the observed measures in which the overt

expression of pain and anxiety appears to be age-dependent.

The Stanford Clinical Hypnotic Scale for children

(SCHS-C) was included as a peripheral measure to glean more

information about the relationship between the ability to

reduce pain and distress, and hypnotic responsiveness. To

determine this, a multiple regression analysis was run with

two independent measures: PBRS-R at baseline and hypnotic

susceptibility, as the independent variables, and PBRS-R first

intervention scores as the dependent variable. However since

imaginative involvement was the hypnotic treatment, only that

group of 16 subjects could be used in the analysis.

The multiple regression analysis indicated that

hypnotic susceptibility does not account for a significant

amount of the variance of the distress scores at first

intervention, beyond that given by the knowledge o+ the

distress scores at first intervention. However the sample of

16 appears to be too small to draw any conclusions.

~~u14s,eL4he~Lusbac~Pu_n~t,uceePcoc_ed,uce

Not all of the subjects who had BMAs had LPs. However

the subjects who had LPs also had BMAs and participated in the

%MA section o-f this study, Of the 49 subjects seen for a LP at

baseline, 37 returned for the first intervention and 22

returned for the second intervention. The greatest attrition

occurred at the second intervention in the older age group,

and resulted in only two subjects in each o+ the three groups. \

In the young group there were three subjects in the

distraction group, seven in imaginative involvement, and six

in the control group. The low number o-f subjects per group

therefore precludes any reliable statement on these data at

the second intervention. Only Data Set A, the baseline and

first intervention data of 37 subjects will be considered.

The relatively large standard deviations (e. g., 6.67

for control young and 7.75 for imaginal old) underline once

again the wide individual differences found in this study.

Moreover, these large standard deviations together with group

means that range from 4.7 (old control group), to 15.45 (young

distraction group), make it difficult to detect group

differences.

B~nrrLefhsufPPRSzR-Qata

fin exploratory analysis of the baselihe PBHS-R scores

o+ the the three groups shows a similar distribution t o that 2 .

seen in the BHA data. The LP mean scores and standard

deviations can be seen in Appendix J. Baseline PBRS-R mean

scores for all groups appear overall t o be somewhat lower than

r 122

the BMA scores (Appendix 61, and support the previous finding

that the BMA is the more distressing procedure.

9i stress: PbRS-F?

The FBRS-R LP scores were analvzed using the baseline

scores as the covariate in an analysis of covariance. The two

raters were used a5 a within-subject factor. The results shown

in Appendix J, were not significant. Despite the lack of

statistical signif icance, the results for the older age group

display a similar pattern o-f distress reduction across'

treatment groups (see Figure 8) a5 those displayed in the BMA

data (see Figure 3 ) . The older children in the distraction

group seemed to be less distressed at first intervention than

either the control or the imaginative involvement group.

EnLn

Jusherneqt-R&izgs

An analysis of covariance using base1 i ne scores was

carried out on the pain judgement scores of the five raters.

The results were overall not significant, with a signi+icant

main effect for Raters only. The omnibus F (F=5.89, p<.001)

indicated that, similar to the %MA results, the raters behaved

differently from one another. A n examination of the marginal

adjusted cell means, indicated that Rater1 and Parent judged

the child's pain on the LP as slightly lower (X=4.05) than the

judgement ratings of the Nurse, Doctor and Rater2 ( X = 4 . & 5 ) .

Sshf=Beeart2ais

An analysis of covariance produced results that were

not significant. Comparing the BMA and LP procedures on

Younger

- - - -

\ Older , \ \

CONTROL DISTRGCTION IMAGINATIVE

INVOLVEMENT

FIGURE 8: LP scores: I n t e r a c t i o n of G r o u ~ and &ge

j on PERS-R scores

,

124

sel f - report pain, the adjusted c e l l means f o r the LP a t f i r s t

in tervent ion (2.58; 2.59, 2.62) were s l i g h t l y lower than those

reported f o r the BMA 13.32, 2.93, 2.86) f o r control ,

d i s t rac t ion and imaginati VP involvement groups, respective1 y .

The lower LP sel f - repart scores confirm tha t the subjects

experienced the LP procedure as less pa in fu l than the BMA.

The anxiety judgement ra t ings of the f i v e ra te r s were

subjected t o an analysis of covariance. There were no

s i gn i f i can t e f f ec t s apart from a s i gn i f i can t main e f fec t f o r

Raters IF=4.5, pi.01). Examination o f the marginal adjusted

means of the c e l l s f o r the f i v e ra te r s ind icates tha t the

Nurse rated anxiety somewhat higher (X43.95) than d i d the

other r a te r s ( X = 7 . 5 , '7.64, 7.81 8 8.1-7, respectively, f o r

Parent, Doctor, Rater2 and Rater l ) .

Self -Repr t Anxiety ------- ---------- There were no s i gn i f i can t ef-Fects f o r the ch i ldren 's

sel f - report anxiety scores on Data Set A a t the f i r s t

in tervent ion using an analysis of covariance. Comparing the LP

wi th the BMA procedures a t the f i r s t intervention, the

adjusted c e l l means f o r the LP procedure (3.09, 2.70, 2.32)

were s l i g h t l y lower than those reported on the BMA (3.31,

2-94, 3.31) +or the control , d i s t r ac t i on and imaginal

involvement groups. This shows t ha t the chi ldren experienced

s l i g h t l y l ess anxiety during the LP procedure than during the

BMA procedure.

I NVOLVEME

.FIGURE 9. Distress scores (PBRS-R) comparing First

and Second Interventi an

126

CHWTER FIVE

DISCUSSION

This study was designed t o determine whether d i s t rac t ion and

imaginal involvement were e f f ec t i ve treatments +or reducing

the distress, pain and anxiety associated wi th aversive

medical procedures f o r young cancer patients.

Basel~nz,tn~the-ELr~ttLn~~r_x~ntLon_

The pat ients" pain and anxiety sel f - reports indicated

tha t nei ther treatments were superior t o standard medical

p rac t ice i n reducing the personal experience of pain or

anxiety a t the f i r s t intervent ion. This i s a curious f i nd ing

and departs from the ob jec t ive measures' resul ts , which

indicated d i f f e r e n t i a l treatment e f fec ts f o r the two age

groups.

However. a5 the Dot P lo t s o+ the sel f - report data

i l l u s t r a t e (see Figure 5 and 71, the baseline pain and anxiety

scores f o r the contro l groups (wi th the exception of the pain

scores f o r the older contro l group) were lower than the scores

f o r the other two groups, This suggests tha t there may have

been some form of b ias i n the group assignment; and second,

wi th low scores of two or one on a f ive-point scale a t

baseline, these scores were not able t o drop and r e f l e c t

change, i f change had occurred. The problem of group

assignment w i l l be discussed fu r the r on, under group

differences. However, the second issue per ta ins t o the

r e s t r i c t i o n o f range of self-report instrument i t s e l f , and

t h i s w i l l be explored here,

The self-report scales that other researchers in this

area have used. all consisted of more than 5 points in a

linear scale. For example, Hilgard & LeBaron (1982) used a

ten-point scale, and Katz (19791 used a seven-point scale.

From their reports, the scales could successf ul ly

differentiate levels of pain and anxiety with sufficient

sensitivity. However, the sample in these studies consisted of

children aged six years and older. In the present study, half

of the sample consisted of children six years and younger,

consequently the researcher considered a seven-point scale to

be potentially confusing. However, in light of the present

findings, which do seem to reflect a restriction of range, a

seven-point scale would have offered greater choice and

provided finer discriminations, a1 though its use would

certainly have excluded children of four years and younger.

Nevertheless, in the interests of more accurate measurement

future studies on pain and anxiety management with children

under the age of seven may benefit from a self-report scale

that permits a greater range, even though its use would

preclude the very young child.

To explore the problem of initial low self-report scores

a little further, an examination of Figure 5 indicates that

four children in the three groups at baseline reported a pain

score of 1, and Figure 7 also shows that at base1 ine five

children reported an anxiety score of 1, The question arises

why these children were included in the analysis, since their

self -report scores indicated minimal pain or anxiety.

In the selection of subjects, the researcher was guided

I

128

by the medical staff on whether or not to approach a

particular child and parent; and the child's statement at the

first interview, whether he or she w a s bothered and distressed

by the procedures, and whether he or she wanted to participate

in the study "about how children handle undergoing a BMA or

LP". In essence, the medical staff identified the children who

found the procedure distressful, and the child and parent then

elected whether ta participate or nat. Using this procedure

six children were included who indicated in their statements

that they were "afraid of the Pokes" and found them upsetting,

and yet these childen were subsequently labeled "topers" by

the medical staff. This type of inconsistency could have been

avoided if a standard cut-off point on the distress measure or

self-report measure (such as a score of 2) had been adopted.

This objective criterion would have standardized subject

selection, and it would have averted the baseline "floor

effect" in the self-report scores and avoided any demand

characteristics that may be inherent in a first interview. The

effectiveness of the treatment as reflected by the child's

self-report may have been more clearly determined.

-

Ase-and-Lrea&mmnt-Effects

In contrast to the self-report results, the objective

. measure findings support the hypothesis that the treatments

would be differentially effective for different age groups. At

first intervention there was a significant interaction between

the children3s ages and their treatment groups, as measured by

judged pain and anxiety, Both treatments were significantly

more effective than standard medical practise +or the older

children. For the younger children on observed distress,

imaginative involvement was significantly more effective than

either distraction or the control procedure, and a trend in

the distraction treatment for the older children was found,

although this did not reach statistical significance.

For the younger children on judged pain and anxiety,

neither treatment was siqnificantly more effective than the

control procedure. Interestingly however, there was a

differential effect between the two treatments: the

imaginative involvement group was judged to be in less pain

and less anxious than the distraction group, Analysis of the

distress scores support this finding, indicating that

imaginative involvement was siqnificantly more effective at

reducing distress than either control or the distraction

treatment. Imaginative involvement therefore appears to be the

most helpful intervention for children aged 3 to 6 years 1 1

months.

For the older- children however, both imaginative

involvement and distraction emerged as significantly more

effective than standard medical practise, on the measures of

judged pain and judged anxiety, as was shown in Figures 4 and

6. The older children's distress scores reflected this

downward trend for distraction only. Whereas both treatments

were helpful to the older children on two of the measures, the

three objective measures are consistent in that distraction

appears to be a beneficial treatment for children aged 7 to 10

years .

Previous studies have demonstrated the effectiveness of

hypnosis in reducing children's pain across a wide age range

of 6 to 19 years (Eellerman, Zeltzer, Ellenberg ti Dash, 1983;

Zeltzer and LeEarun, 1982). The EMA evidence from the present

study indicates that the age group not included in previous

studies ( 3 to 6 years 11 months) were best helped by imaginal

involvement. Moreover, the present study found that children

aged 7-10 years were observed to respond to both treatments,

however the data suggest that the older children responded

best to the distraction treatment. This contrasts with Zeltzer

& LeBaran's (1982) findings. There are plausible explanations

for the different findings in the Zeltzer and LeEaron (1982)

and the present study.

The first issue is why distraction should have emerged

as a helpful technique for the older children. One possibility

is the reliance on self-coping which was built into the

distraction treatment. Unlike the imaginal involvement

technique, the distraction procedure encouraged the children

to initiate active deep breathing whenever they became aware

of "scary feelings" and to select a physical distractor that

would be the most hef pf ul at that time. The case of 8 year old

Bobby may be used to illustrate the development of coping

skills, by focussing on the observations o+ his behaviour and

his statements over the three sessions.

Bobby was well-known on the ward as "the screamer"

because "I have to scream!" Over hi5 years a5 a patient Bobby

had learned that screaming helped him get through the

frightening and painful BMA. At baseline Bobby's mean distress

score was 15.5 (the mean for the older group was 101 and he

rated himself 4 out of 5 for pain, and 4 out of 5 +or anxiety.

At baseline, Rater1 noted during the approach phase that bobby

is "extremely apprehensive, complains to Mom 'What are they

doing ?... I want to wait a minute'". During the anesthetic: "He

anticipates pain 'Don't do anymore, give me a break!' He

questions everything. 'I have to scream' and does so

repeatedly". During the BMA: "He wants to see the needle, and

begins to cry in anticipation. Procedure continues. 'Are you

done? Hurry hurry please!" Says he feels pressure not pain".

The rater noted that her score of 16 did not accurately

portray the intensity of Bobby's anxiety, although it did

reflect his gross behaviour during the procedure.

Bobby who is a gregarious child was easy to engage

durinq preparation prior to the first treatment intervention.

Breathing w a s focussed on, rehearsed, and the simi lari ties

between deep big breaths and screaming were explored. The

point was made that essentially deep breathing and screaming

achieve the same results, but he should use whatever helps him

the most and that "it was OK if he wanted to scream". He also

chose 2 pop-up books that interested him to look at durinq the

procedure. Observations by rater1 during the approach were a5

follows: "A little nervous, smiling and joking with staf-f. Has

a little cuddle with Mom, then willingly positions himself".

During the anesthetic: "Jet given. He's coached to breath, and

breathes. Apprehensive but co-operating beautifully. Inquires

132

about procedures 'I'll tell you when I'm ready'. More

questions. Lies with his head on his arms as a pillow". During

the BMA:",..Feels pressure of needle, breathing well, tries t o

relax. Says 'I'm OK!'". For this procedure Bobby obtained

mean PBRS-R scores of 7.5 and rated himself 2 for pain and 2

for anxiety.

During preparation priar t o the second intervention,

Bobby proudly c0mmented:"Last time I didn't scream. I don't

have t o scream anymore". His mother added affectionate1 y that

Bobby is handling the BMA so much better that she left her

ear-plugs at home. Bobby achieved a mean PBRS-H score of b

during this BMA and rated himself 2 for anxiety and 2 for

pain.

The emphasis on managing oneself and taking some

responsibility for the process of coping with the aversive

situation, may indeed have been more developmentally

appropriate to school-aged children than the pre-school child.

Erickson (1963) noted that the developmental task of the

school-aged child during middle childhood is to develop a

sense of industry, and use his or her abilities in ways that

will be satisfying t o him or her and acceptable t o society. He

added that the risk lies in feeling unable t o perform the task

required of him or her and developing a sense of inadequacy

and inferiority. The desire t o cope satisfactorily with the

difficult BMA procedure may be regarded a s extraordinary, but

nevertheless for some a task t o be mastered.

further explanation for the different results between

the present study and the Zeltzer and Le%aronss study is that

133

the Zeltzer and LeBaron distraction technique consisted of

verbal distraction and breathing. The present study adopted

and elaborated upon these techniques by adding specific

objects t o the surgery room, such a s pop-up books and bubbles.

These additions may have made the treatment mare viable far

school-aged children in pain.

As regards the efficacy of imaginative involvement with

older children, the present studyPs findings accord with those

of Zeltzer & LeBaron (1982), that hypnosis is successful in

reducing pain and anxiety, and that it generally did not

eliminate these symptoms entirely.

Y ~ y e q ~ r - C h L L d c e n

It i s interesting that overall, distraction was not

found t o be e-ffective for the younger children. The addition

of bubbles t o the surgery room created an immediate source of

delight and interest. Invariably the children responded by

reaching out t o catch the bubbles and either asking the

therapist t o blow more, or began blowing themselves. In those

moments their apprehension about the farthcoming procedure

seemed forgotten. However, distraction may have provided only

momentary relief from the pain and anxiety of the procedure

and those moments palled next t o the procedure. Moreover, the

younger children's ability t o manage on their own was limited,

and they relied more heavily on staff and therapist than did

the older children. Therefore, the present form of the

distraction technique with its reliance on self-coping may

have been less suitable for t h e younger group.

A further question that arises from the results at first

intervention, centres on why the younger children consistently

appeared t o d o best with imaginative involvement . Reducti ons in distress, pain and anxiety were achieved in the first

intervention and, as Figure 9 indicated, at the second

intervention the reductions were maintained with little

further change.

The response t o imaginative involvement within the first

intervention i s very encouraging for an age group about whom

little i s known with respect t o pain management. It i s

possible that using a favourite stary as the hypnotic

framework may have intensified the child's involvement and

enhanced feel i ngs of romf ort . The case of 5 year old Samantha may be one such instance

of the above process. Samantha was a highly imaginative,

spontaneous child who always came ta the clinic with

personalized toy animals. At baseline her mean distress score

was 20 (one of the higher distress scores in the sample). and

she rated herself 5 for pain and 5 for anxiety. Observstions

at the approach phase by rater2 noted "Samantha is reluctant

t o enter the room. Hanging onto Mom and crying. Wanted Mommy

t o lift her onto the table. Eegan talking quickly (giving the

physician instructions) 'DonFt push too hard!"' At thz

anesthetic: "Samantha is very frightened had t o be restrained

by nurse and held by mother..." During the BMA, she "directed

questions and commands t o h e physician talking in a high

shaky nervous voi ce" . +i During the first intervention preparation period, the

therapist negotiated a "contract" with Sam that by the time

1'55

her davourite story "Grandma Tiddly and her animals" w a s

finished, the EMA would be finished and the band-aid an.

Sugqe5tionz, far camiort, time-reduction and exciting 5upriz.er

in the stery were also given. Observations by rater2

noted:"Enters crying wants her brother, clinging to

Mom ... talking constantly. During the anesthetic: "Cantinver to

talk but relaxes when Leora talks t o her about the animals.

M a 5 only rigid for the 'jet' and relaxed during the lacal

anesthetic; listening t o story". During the EMA: "Seems .

unaware of needle inserted. Becomes very quiet: says 'ow'

during the a-spiration. Muscular twitches, her body seem5 to be

in constant moticn, even though she rests. Really listening ta

the story...". Her mean PBRS-H score was 7.5 and self-report

pain remained at 5 and self-report anxiety dropped to 1.

A t second intervention Samantha's peripheral blaod Count

suggested a relapse. Thus a BMA and biopsy had t o be done.

Preparation prior t o the intervention was brief but reiterated

the "contract", reminding Sam of her previous success and

recapitulating part of her favourite story with suggestions

for exciting surprises and com-Fort, so that she became less

frightened. Observations by Rater2 noted: "Looks very

frightened but got onto the table without any fuss. Calour

poor, looks unwell". During phase 2: "Reached for Mom's hand.

Engrossed in Leora's story. Sam very co-operative, didn't

appear to experience much discomfort." During phase 3: "Still

ccroperative, quiet. Loving the stories. A 1 i ttle whimpering

when experiencing real pain. Crying more now, tired. Procedure

not going well, and taking a very long time. Biopsy needle had

136

t o be inserted 3 times...." The mean PBRS-R score was 9.5 and

Sam rated herself 3 for pain and 2 for anxiety.

The success of the yaunger children w i t h the imaginative

involvement condi tion prompted a closer examination of thi 5

groups' baseline t o first intervention scores. When the

criterion of a reduction of more than 5 points on the Distress

scale was adopted, the group's raw scores clearly divided into

two clusters. One group consisted of 4 children who

demonstrated a greater than 5 points reduction on distress,

who were thus regarded as prompt responders. The second group

of 5 children appeared not t o respond t o imaginative

involvement and continued t o manifest levels of distress

similar t o baseline scores. The small numbers make this

discussion only speculative, however it was interesting t o

note that the children whose distress scares fell more than 5

- points all had high hypnotic susceptibility scores ( 5 or & I ,

whereas the children who showed less than 5 points and who

appeared to be relatively unresponsive t a the treatment, had

moderately l o w t o low hypnotic susceptibility scores (2 or 3 ) .

From these results it seems that not all, young children .

will be responsive to and be helped by imaginative

involvement. However, those who are helped may attain highly

significant reductions in distress; individual differences in

hypnotic susceptibility scores may be important predictors in

selecting the best treatment. Although kentative, the results

support the relationship between hypnotic susceptibility and I

the ability t o reduce pain, and add t o Hilgard and LeEaron's

137

(1982) finding that hypnotic talent is necessary for a

reduction of sensory pain. Although the small numbers caution

against gross generalizations these tentative findings

nevertheless appear worth pursuing in future research with

this and older age groups.

In general, the younger children's results have

practical significance for the clinician. First, it may be

helpful to include an hypnotic susceptibility test which can

be administered briefly and within the context of a game,'

prior ta the selection of an intervention technique. Second,

it may be that younger children who do not immediately repond

to imaginal involvement should not be provided with further

similar interventions. They might be better helped by other

psychological techniques which do not rely on imagination and

hypnotic talent.

While the two techniques, distraction and imaginative

involvement were designed to be as different as possible, it

must be noted that in terms of general psychological practice

these two treatment approaches may not be distinct and unique.

They can, for example, be combined : distraction can be used

within a hypnotic trance with great effectiveness so that

distraction in this context could be considered as a hypnotic

technique. However, this was not the case in the present study

where the distraction condition involves behavioural

distraction with no attempt to create a trance.

Eirst,ns~,Snrsn~,&st,~r_v_e_n_LS~n_

.There were differential effects for the two age groups

on observed leve ls of pain and anxiety from the f i r s t t a the

second in tervent ion session. This r esu l t s supports a1 1 the

previous studies t ha t noted older ch i ldren demonstrate lower

leve ls of pain and anxiety than do younger ch i ldren (Katz e t

dl., 1980; Jay, e t a l . 1983: LeBaron & Zeltzer, i n press),

although an equal amount of s t ress i s experienced by the two

age groups (LeBaron Zel tzer) . The s i gn i f i can t e f fec t f o r age

underlines the importance o-f including age as an independent

var iab le i n research tha t uses object ive instruments wi th

children, f o r there are d i f f e r e n t i a l behaviours fo r ch i ldren

of d i f f e ren t ages w i th in the same s i tuat ion. Qn sel f - report

instruments pain and anxiety are not age-dependent.

A consistent f i nd ing on d is t ress and se l f - repor t of pain

and anxiety was tha t a l l groups showed reduction i n distress,

pain and anxiety between f i r s t and second intervention. {A

breakdown by Group and Age of t h i s Session e f f ec t can be seen

i n Figure 9). A t f i r s t glance t h i s suggests tha t as a funct ion

of an increase i n the number of pa in fu l procedures, a l l

ch i ldren across a l l ages w i l l d isplay less distress, pain and

anxiety. This i s both contrary t o previous l i t e r a t u r e and

contrary t o the experience of the oncology c l i n i c staf+,

before the present treatment study was i n i t i a t ed . A more

p laus ib le i n te rp re ta t ion i s tha t the contro l group d i d not

remain a "pure" contro l group, and tha t i t became contaminated

by the treatment e f f ec t s from the d i s t rac t ion and imaginal

i nvol vement groups.

Contamination of the contro l group was noted by Barber

and Cooper (1972) i n t h e i r laboratory study of d i s t rac t ion -

They concluded tha t there i s no such th ing as a "pure" control

group since subjects spontaneous1 y use techniques t o minimize

discomfort. I n the present study t h i s became apparent when one

of the parents said the fo l lowing t o her c h i l d i n the presence

of the therapist: "They are going t o watch you today and sea

haw much bet ter you do t h i s t ime!" Having the experimenter

s i t t i n g and observing during a contro l condi t ion may have been

viewed by other contro l ch i ldren as encouragement t o do

better.

I n short, the inc lus ion of a standard-procedure contro l

group w i th in the present study created p rac t i ca l and e th i ca l

d i f f i c u l t i e s . By the second in tervent ion i t was d i f f i c u l t t o

ascertain whether the contro l group remained 'pure", and also

d i f f i c u l t t o contend wi th the s t a f f ' s natural desire t o apply

the novel and seemingly e f f i cac ious techniques t o a l l

children. For example, on a number of occasions when a contro l

c h i l d was displaying high l eve l s of d is t ress the nurse would

use some of the d i s t rac t ion techniques, and intervene i n a

manner tha t she had not displayed p r i o r t o the present study.

Discussion afterwards confirmed tha t the d is t ress and needs of

the c h i l d a t tha t moment were more pressing than the research

needs: The medical s t a f f ' s model1 ing of the therapis t 's

techniques spoke t o t h e i r wi l l ingness t o learn more e f f ec t i ve

ways of dealing wi th a s t ress fu l job though t h i s was sometimes

counter-productive f o r the research.

It was evident as the treatment program progressed t ha t

i t was becoming increasingly d i f f i c u l t t o prevent the s ta f f

from using and prac t is ing the techniques tha t they observed t o

be e+fective. The staff assisted in the implementation of

distraction +or a child in that treatment group, and it was

difSicult for them at times to revert to their standard

medical approach for a control child who was in distress, For

these reasons, as the interventions increased the control

group became more diluted by the distraction techniques in

particular, becoming less a true comparison group, and more a

third treatment group. The significant finding of a reduction

in distress, observed and self-report pain and observed '

anxiety from the first to second intervention should be

understood in this light.

1he_-rrrec_e_sn-affGh~n_9e_

In reviewing the process of therapeutic change during

the present study, it was clear that the objective measures

were capturing only the more obvious and situation-specific

changes. Several facets of changing behaviour were noted. Qne

facet, not captured by the instruments, was the child's

changing thoughts. Often change in the treatment subjects'

behaviour during the medical procedures seemed to be preceded

by a cognitive change, articulated by the child in

anticipation of the procedure. For example, 7-year-old Nathan

announced to his mother at breakfast prior to his second

imaginative involvement intervention: "Today I'm not scared!";

4-year-old Bonnie asked her mother whether the lady with the

bubbles would be at hospital, and talked about blowing bubbles

on her way to the clinic: 6-year-old Lesley came downstairs on

the morning of her appointment and said to her parents, "I'm

141

thinking about being strong today. I think it will g o fast."

All three of these children showed a positive change during

the subsequent BMA.

Progress was often observed during the procedures, in

terms of a reduction of distress and quicker recovery peri~ds.

The changes were frequently subtle and, though noted in the

raters' observations and judgement ratings, were not of a sort

t o be identified on the PBRS-R checklist. The measure as

found t o be a sound behavioural instrument but its checklist

format had limitations. Sachum and Daut (19812 in their

critique of the PBRS indicated that the instrument could be

improved by including an intensity index. This recommendation

has been followed through by LeBaron & Zeltzer (in press).

This modification would also improve the instrument's

sensitivity t o the process of behavioural change.

The objective reports of distress, pain and anxiety,

gave overlapping but not the same information a s the

self-report of pain and anxiety. Children reported that

anxiety was best relieved by imaginative involvement, and this

subjective report found some support in both age groups for

the objective rating of anxiety. However, for pain the -

observers judged the children's pain t o be best reduced by

imaginative involvement, while the children's self-report

indicated that n o one condition helped significantly reduce

the private experience of pain. Continuing the practice of

using objective and subjective measures for applied research

is strongly endorsed. The joint use provides clinically

meaningful, more complex, and more finely differentiated

information.

Ind iv idual Di f f erences ----------------------

One of the most s t r i k i n g observations i n t h i s study was

how chi ldren of the same age and sex could vary so widely i n

t h e i r response t o the pa in fu l procedures. few chi ldren

adopted a detached or s t o i ca l a t t i t u d e towards the procedures,

and even though they reported some anxiety and pain

afterwards, they demonstrated only some muscular r i d i q i t y ,

wi th l i t t l e distress, pain or anxiety during the procedures.

Other ch i ldren were hyperv ig i lant t o any sensatian and became

extremely disturbed by r e l a t i v e l y minor pain-producing

st imulat ion. A major research endeavour tha t remains t o be

undertaken i n the i d e n t i f i c a t i o n of var iables tha t produce

these ind iv idua l differences. With such ident i - f icat ion

pat ien ts and in tervent ions can be matched.

From observations during t h i s study, i t would appear

tha t the fami ly 's a t t i t udes towards pain and disease p lay a

primary, but not always a clear-cut r o l e i n t h e i r ch i l d ' s

behaviour. There were a number o+ occasions when a parent

would convey a message of coping or not-coping t o the c h i l d

which appeared t o a f f ec t the ch i l d ' s subsequent behaviour.

Emotionally distraught parents seemed t o e l i c i t one of two

extreme responses i n t h e i r children: the c h i l d would e i the r

act out high l eve l s of anger and distress, or would have

developed a pro tec t ive response towards the parent and

therefore would over t l y cope remarkably well. I n contrast, i t

appeared tha t parents w h o had a pragmatic at t i tude, made

little fuss and conveyed confidence in their children's coping

ability did the best.

Re1 iginus and cultural factors were also 1 i kel y powerful

determinants of a child's style of pain management. This

conversation between the therapist and 5 year-old Natalie

illustrates the role of religious bef ief . Therapist: "What helps you when you have the poke? 'Cause you

did so well today!"

Natalie: "Having Mommy with me"

Therapist: "What else helps?"

Natalie: "Having God with me".

Therapist: "What does Mommy do t o help?"

Natalie: "She holds my hands".

Therapist: "What does God d o t a help?"

Natalie: "He takes my fear away".

Although such anecdotes are dramatic, they are merely

clinical observations, and systematic research is needed t o

determine the effects of parental messages and attitudes on

chi ldrens' pain behavi6ur.

A +urther area that needs systematic investigation is

the self-taught copers, children who have learned t o cope on

their own. Throughout the present study children reported

strategies that they employed and found helpful. For example,

a 10 year-old boy mentioned: "I get myself t o relax like a wet

noodle!" The strategies that these capers use would be both

.helpful and interesting t o workers in this field.

144

G r o u ~ Di f f er en ces ---- ------------ Baseline score differences between the three groups,

(the distraction group tended to show the highest levels a+

distress and self-report pain and anxiety and control the

lowest), were not initially apparent during the study. A

re-examination of the clinic system indicated that this

bias may be due to two sources. Far the purpose of the

study, children were randomly assigned to groups on the

basis of entry into the clinic for the first intervention

BMA. Generally the clinic assigned 2 to 3 children per

morning for a BMA, and the Head Nurse ensured that not more

than one difficult child was assigned +or the morning.

There+ore during a day with three children, only one child

of the three children would be difficult. This

systematization may have introduced some inadvertent bias.

The second source of bias was more obvious. On three

occasions a child randomly selected for the control group

became very distressed during the BMA and the nurse

spontaneously gave the child the distraction objects. The

child was then re-assigned to the distraction group. With

the relatively small sample, it would take on1 y a f e w

highly distressed children who were initially placed in the

control group and then perforce reassigned tu the

distraction group, to alter the distribution o+ the twe

groups. This is the more serious seurce of bias, and f

epitomizes a clash between clinical and research cmcerns

that is not uncommon in research carried out in an intense .

clinical setting.

Conci ~15i an

The notion that cognitive processes play a mediating

role in pain sensation finds support in this study. The

efficacy of the psychological treatments of distractlm and

imaqinative involvement with primary school children. and

imaginative involvement with pre-school children, speaks to

the utility a+ psycholcqical interventions for altering

observed pain and distress.

Pain is a complex phenomenon: it is a sensory

experience, yet also an emotional one. In the present study

the treatment of pain was inextricably intertwined with the

treatment of anx i et-y. The si mu1 taneous treatment of both

pain and anxiety was relatively easy to effect, and was

deemed essential to any effective intervention for acute

pain. The results consistently indicate that younger

children's distress was best alleviated by imaginative

involvement, whereas the older children's observed pain and

anxiety was best reduced by both ~sycholegiral treatments

when campared to standard medical practice. 0f hte tow

treatment methods distraction emerged as particularly

helpful for the older children.

The present study demonstrated that psychological

methods that do not require a great investment of time can

be beneficial in reducing children's distress, pain and

anxiety during BMAs. The therapeutic effects of the timely

146

use af blowing bubbles or actively relating a favourite

story become evident within the first intervent~un. The

benefits of children7s improved coping accrue hevand the

child, and contribute to improving the climate of the

clinic and the medical sta-f-f's work-satisfaction. The study

demonstrates that psychological techniques have important

benefits far children in medically taxing situatims.

147

APPENDIX A

HYPNOTIC THERAPEUTIC METHOD

The Switch technique

(Adapted from R. Pearson's presentat ion (1982, December).

Pain con t ro l a t the Ericksonian In te rna t iona l Conference,

Phoenix, Az.)

"Let me show you something, pu t your hand up l i k e t h i s (hold ing l e f t hand v e r t i c a l l y 10" from face) and l e t ' s pretend the sk in i s translucent, t h a t i s , you can s o r t of see through your hand. A s you r e a l l y look a t it, you can see the o u t l i n e of bones and muscles and same blood vess l r and l o t of l i t t l e th ings inc lud ing some very very f i n e th ings t h a t look l i k e wires, they' re r e a l l y nerves, but they look l i k e wires. They s t a r t underneath the f i nge r n a i l s and are so very very f i n e t h a t i t s hard t o see them...If you look very c lose ly y o u ' l l see t h a t they s t a r t t o wind around each other and as they go up your f ingers, they wind around more wires coming from other p a r t s o f your f inger , and they get t h i cke r as they go up your hands and i n t o your w r i s t s and up your arms. I ' v e got t o look and see, today my wires are purple. What co l our are yours? (Chi 1 d answers) Good ! Then the wires go up your shoulder and i n t a your neck. I n your neck there are other wires from a l l pa r t s o f your body, from your l e f t l e g and from your r i g h t leg, from your tummy and from your back... Some people have a specia l w i re from t h e i r knees, and soem even have a wi re from the t i p of t h e i r nose...and a l l t h e wires go up i n t o the neck and i n t o the black box i n the middle o f the head...and i n the black bsx there are l o t 5 o f switches. Now everyone has t h e i r own p a r t i c u l a r k ind of switch. Some people have switches l i k e those i n a TV set, some have switches l i k e those i n a car, o r i n an aeroplane. Some are d i a l or rheostat switches and others can simply be c l i cked o f f . Have a c lose look.. . what k ind of swi tch do you have? (or i f the chid1 i s uncerta in) what k ind would you l i k e t o have? ( c h i l d g ives an answer) Now look c a r e f u l l y underneath each of those switches there are signs: one s ign says ' le- f t leg ' another swi tch says ' r i g h t leg'. . . .Now what I ' d l i k e you t o do i s c a r e f u l l y f i n d the swi tch t h a t goes t o your l e f t hand. Once youZve found i t l e t me know by nodding your head. . . . Now what t h i s i s a l l about i s th ings t h a t h u r t coming from your body; t he message passes up those wires, those nerves and t e l l t he b r a i n 'Hey my l e f t l e g hur ts ' or 'my r i g h t ankle hurts ' . So i f you t u r n the swi tch o f f o r t u r n i t down, then i t w i l l t u r n down the h u r t message...So when I

c o u n t t o t h r e e 1 7 d l i k e you t o t u r n t h e s w i t c h down.. -1,. 2.. 3.. cl i c k . N a w I ' l l show you ( t h e r a p i s t t a k e s a s m a l l n e e d l e ) . L e t ' s test t h e o t h e r hand, t h a t h a s its s w i t c h sti l l on w i t h t h i s needle. N o w t h a t p a i n f e e l i n g is a 1 0 ! OK now l e t Z s test t h e l e f t hand and see what number comes...you can j u s t l e t i t happen, and see what your hand f e e l s l i k e ( w a i t s far t h c h i l d P s r e p l y ) . Now t a k e t h e n e e d l e i n your own hand and m a k e s u r e i t f e e l s l i k e a 3 . . . 1 7 m c u r i o u s how lonq it w i l l l as t . .maybe i t w i l l l a s t a f e w m i n u t e s and maybe i t w i l l last 10 minutes . . "

A f t e r a c h i e v i n g p a r t i a l a n e s t h e s i a i n t h e hand, t h i s t e c h n i q u e

c a n b e p r a c t i s e d on o t h e r p a r t s of t h e body and f i n a l l y on t h e

i l i a c crest area af t h e l o w e r back where t h e BMA is

V i s u a l i z a t i o n of t h e s w i t c h c a n b e combined w i t h o t h e r

h y p n o t h e r a p e u t i c t e c h n i q u e s s u c h a5 p a r t i a l d i s s o c i a t i o n : " N o w

t h a t you h a v e t u r n e d your p u r p l e p a i n s w i t c h down, I wouldn ' t b e

s u r p r i s e d i f you f e l t a k indof n i c e l i g h t f e e l i n g so t h a t i f you

wanted t o t h e p a r t of you t h a t wan t s t o see e v e r y t h i n g c a n f l o a t

up and sit on t h e cei 1 i n q and watch u s a 1 1 down below.. . I wonder

what you c a n see from t h e r e ? Who l o o k s t h e f u n n i e s t ? ' '

APPENDIX B CONLSENT FORM

B . C . CHI WREN ' S HOSP 1 TAL : PEDIATRIC ONCOIM3Y PSYCH0UX;ICA.L S'I'UDY

You are invi ted t o take pa r t i n a study of haw children cope with painful medical procedures, such as Bone Marrow Aspirations and Lmdmr Punctures.

If you decide t o take p a r t i n t h i s study, our Research Associate wi l l ask you a few questions a f t e r t h e medical treatments, these w i l l include questions about childhood fea r s .

Any information about you and your family i n t h i s study w i l l be confident ial . I f we write t h e r e s u l t s of the study f o r a profes- s ional journal, we w i l l r.ot use your name.

Your decision whether o r not t o take p a r t w i l l not change your medical care i n t h i s hospi ta l . I f you decide t o take p a r t , you can change your mind and s top at any t i m e .

I f you have any questions please f e e l f r e e t o call LRora Kuttner o r Dr . Teasdale ,at (604) 875-2116. Leora Kuttner can be reached i n the evening and on weekends at (604) 294-0986. You w i l l be given a copy of t h i s form t o keep.

You are W i n g a decision whether o r not t o take p a r t i n t h i s study. Your signature m a n s t h a t you have decided t o take p a r t and t h a t you have read and understand t h e information about the study given

explained t o you.

Signature (pa t i en t ) Signature (mother )

Signature ( f a t h e r ) Signature (researcher)

Signature (witness) Date.

PROCEDURE BEHAVIOR RATING SCALE - REVISED

.......................... CHILD : .......................... U T E R :

PROCEDURE: ........................ DATE: . . . . . . . . . . . . . . S e d a t i o n Yes/No

OB S ERVATIONS :

SRY I

CLING I

PAIN ! I

S CREAM I

I STALL I

F U I L f 1

REFUSAL POSITION

RESTRAIN

S u p p o r t p e r s o n

I

i ,

Comments :

..................

..................

I ANXIETY SELF-REPORT: '

W S CULAR RIGID I TY

EMOTIONAL SUPPORT

REQUESTS TERMINATION I

I

- - t

PERS-R: OPERATIONAL DEFINITIONS -------------------------------- ITEMS:

Crv: Tears i n eves a r running down face.

Cling: Phys ica l ly holds on t o parent, s i g n i f i c a n t other, or

nurse.

Fain: Savs "Ow". "Duch". "It hurts" , "Yau're hu r t i ng me". atc.

Scream: No tears, raises voice, verbal or non-verbal.

S t a l l : Verbal expression a+ delav {"Wait a minute". "I'm not

ready yet". etc. 1 or behavlo~tra l d e l av l ionares nwse ' s

i ns t ruc t i uns ) . F l a i l : Randum gross movements of arms andlor legs, without

i n t e n t i o n t o make aggressive cantact.

Refusal posi t inn: Does nnt +al low ins t ruc t i ons w i th regard to

body placement on treatment table.

Restrain: Has t o be held down due ta lack af ca-uperativeness.

Muscular R ig id i t y : Any of the fo l lowing behaviours: Clenched

f i s t s . white knuckles. g r i t t e d teeth. clenched ~aw, wrinkled

brow, eyes clenched shut. contracted limbs, body s t i f fness .

1O. Emotional support: Verbal or nun-verbal so l i c i t a t i o n of hugs,

physical comfort. or expression of empathy from parent,

s ign i+ ican t other. or nurse.

11. He~ues ts Termination: Verbal ly asks/pleas tha t procedure b e

stopped.

r APPENDIX I)

JUDGEMENT RATING SCALES FOR P A I N AND ANXIETY

(For Nurse, Doctor and Observers)

............... RATING SCALE NAME : - ............................. DATE : - BY : NURSE 1 DOCTOR / ORSERVER PROCEDURE:

1 5- s e v e r e pa in /d i scoarfor t I I 5= s e v e r e a n x i e t y I

t' P U - A!WETY

JUDGEMENT R A T I N G SCALES FOR P A I N AND ANXIETY

(For t h e Parents)

1 -APPROACH

2 ANASTHETIC

3 PROCEDURE

PARENT RATING SCALE NAME: ......................... D A T E : . . . . . .......... B Y : MOTHER / FATHER / OTHER PROCEDURE: LP / BM NOW/ PREVIOU

__--_---------- 1 2 3 4 5

1 2 3 4 5

DATE PREVIOUS: ...... ANXIETY 1

1 APPROACH 1 2 3 4 5

2 ANASTHETIC 1 2 3 4 5

d

1 2 3 4 5 .

1 2 3 4 5

1 2 3 4 5 t

I= very l i t t l e p a i n / d i s c o m f o r t

3- moderate p a i n / d i s c o m f o r t

L: i

1- very l i t t l e a n x i e t y

3s moderate a n x i e t y

. 3 PROCEDURE I 1 2 3 4 5

1 = v e r y l i t t l e p a i n l d i s c o m f o r t

3 = moderate p a i n / d i s c o m f o r t

1 2 3 4 5 t

1= v e r y l i t t a n x i e t y

3= moderate a n x i e t y

I 5 = s e v e r e pa in / d i s c o m f o r t 5= s e v e r e a n x i e t y

i\ ge Hypnotist

Details on the pages that Sollow Score A or - ,

1. Hand lonering

2. Arm Rigidit!

3 . TI' - l'isual

(I)--

1 2 )

(3 1

1

1

6. Age Regression

Total Score

t 6)-

I I i

Scorcc if arm and hand lowers at least 6 inches hy end of 10 seconds.

1. A R M RIGIDITY Describe movement:

Score+ if arm bends less than 2 inches by end OF 10 seconds.

Program preferred

(3) \'isual Do you s& i t ? Is picture clear3 Is it hlack and white or cold! \\'hat's happening? (Detail oi' action)

Score; if child reports seeing a picture comparable to ilctual viewing.

, ) Auditory Can you hrdr it:' Is it loud enough? Sound reported (\Vords. sound effects, music, etc.)

Score+ if child rcports hearing some sound clcarly.

3. DREAM l'erbatim account of dream:

Score + if child has an experience comparzlble to a dream, with some action. This does not include vague, fleeting thoughts o r feelings without accompanying imagery.

-

6. AGE REGRESSION

Target event:

\\'here arc you?

What a re you doing?

How old a re you?

byhat are you wearing?

How did it seem to be back there?

\Vas it like being there o r did y)u just think about it? .

Other:

Score - if child appropriate responses and some experience of being there.

--

Total score

AITENDIX G Results f r o m the BMA Procedure

Data Set A

RATER 1. ......................................................

CONTROL DISTRACTICIN 1MAG.INVOLVEMENT Y o u n g O l d Y o u n g O l d Y o u n g O l d

Easel. mean 10.50 7.75 18.25 11.88 15.22 10.14 5.d- 6.91 5.23 4.59 5.62 6.46 3-76 n 8 8 8 8 9 7

.................................................. Int . I mean 8.75 8-13 13.88 6.75 8-55 8.14

5.d. 5.50 4.02 4.42 5-34 3.81 5-21 n 8 8 8 8 9 7

RATER 2. .....................................................

CONTROL DISTRACTION 1MAG.INVOLVEHENT Y o u n g O l d Y o u n g O l d Y o u n g O l d

.................................................... Basel. mean 9.25 7-38 16.86 11.13 15.11 10.00

s.d. 6.76 4.96 5.4 4.88 6.62 5.66 n 8 8 8 8 9 7

.................................................... 1nt.I mean 9.38 8.25 13.75 6.88 7-78 7.29

s.d. 5.48 2.38 4.46 5.25 3.49 5.94 n 8 8 8 8 9 7

T o t a l N=48

Data Set E

RATER 1. .......................................................

CONTROL DISTRACTION 1MAG.INVOLVEMENT Young O l d Young O l d Young O l d

..................................................... Basel. mean 11.33 10.75 19.17 12.25 16.33 9.50

5.d. 7.74 6.24 2.91 4.92 7.34 6'.25 n & 4 c5 4 6 4

.................................................... 1nt.I mean 10.00 7.50 14.83 7.00 10.33 7.25

5 , d. 5.33 4.65 1.83 6.83 2.5B 5-25 n 6 4 6 4 4 4

..................................................... Int. I1 mean 8.67 7.00 11.50 6.00 9.50 5-50

s.d. 6-56 2.70 2-95 4.32 3.08 3.70 n 6 4 6 4 b 4

RATER 2. .......................................................

CONTROL DISTRACTION 1MAG.INVOLVEMENT Young O l d Young O l d Yaung O l d

1nt.I mean 10.17 8.00 14.83 7.00 9.17 6.25 sod. 6.11 2.45 2.32 6-48 3.13 5.32 n 6 4 & 4 t, 4

-----------------------------------________________________________________-----------------

Int. I1 mean 9.83 6.75 10.33 4-75 9.33 5.00 s. d. 6.88 2.22 3.39 4.27 3.98 3.46 n 6 4 & 4 & 4

Total M=30

AFPENDIX I

Correlation of a1 1 A n x i e t y Scares

PBRS-R NURSE DOCTOR R A T E R l RATER2 PARENT SELF-R

D a t a Set A

CONTROL D I S T R A C T I O N 1MAG.INVOLVEMENT Y o u n g O l d Y o u n g O l d Y o u n g O l d

B!lSELLNE ........................................... NURSE 9.50 8.14 13.29 10.13 10.44 10.29

s.d. DOCTOR

s.d. PARENT

s . d . .+.

R A T E R l 5.d.

RATER2 s.d.

n FIESI-L!!!TEEVENTIQN ................................ NURSE 8.13 10.14 11.57 8.50 8.11 8.57 s. d.

DOCTOR S-d.

PARENT S-d.

RATER1 s.d.

RATER2 s.d. n

Total N=46

D a t a S e t B

....................................................... CONTROL DISTRACTION IMAG-INVOLVEMENT Y o u n g O l d Young O l d Young O l d

E e s E w z ------------------,--------------------------- NURSE 5.20 6-67 7.60 6.25 6.83 6.2%

5.d. 1.79 2.08 1.14 2.36 2.21 2.22 DOCTOR 4-80 5-67 8-20 5-30 6-00 5-23

s. d. 1.10 1.52 1.64 2.38 2 . 1 1.50 PARENT 5.00 6.67 7.80 6.00 5.83 5.25

5. d. 1.00 1.15 1.30 2-00 2.32 2.22 RCITER 1 5.40 5.33 7.00 6.00 6.83 5.00

5. d 1.52 0.58 1 . 4 2.45 1.94 2.1A RATER2 6.20 6.67 8.00 6.66 6.83 4.75

s. d 1.64 1.15 2.12 1.82 1.14 2-22 n 5 -3 5 4 6 4

FLESLL~lEfENFhf!!!! ................................. NURSE 5.20 5.67 7.89 5.75 6.17 4-75

5.d. 0.84 1.15 1.48 2.99 1.17 2.22 DOCTOR 5.20 5.67 7.00 4.25 5.33 4.00

s.d. 1.79 2.08 1.22 1.50 1.37 1.83 PARENT 4.60 5.00 7.20 4.00 5.50 4.25 s. d. 1.95 1.00 1 1 4 1.38 2-06

RCITER 1 4.20 5.00 6.40 4.50 5.00 3.50 s.d. 1.30 1.00 1.34 2.65 1.67 1.29

RATER2 6.00 6.33 6.80 4.75 4.83 3.00 s.d. 1.73 0.58 0.84 1.26 1.17 1-41 n 5 3 5 4 6 4

SECOND-INIERVENIZDN ................................ NURSE 6.00 4.33 7-00 3.50 6.17 4.75

s.d. 2.35 0.58 1.58 1.29 2.79 1-70 DOCTOR 4.60 5.33 5-00 3.25 5.17 4.25

s.d. 1.82 1.15 1.87 0.96 1.72 1-50 PFIREMT 4.40 3.67 4.89 3.50 4.67 4.75

s.d. 1.52 1.53 1.10 1.73 1.51 1.89 REITER 1 4.80 3.67 5.20 2.75 4.00 4.50

s.d. 1.92 1.53 0.84 0.96 1.41 1.73 RATER2 6.00 6.67 5.20 2.50 4.17 4.75

s.d. 1.41 0.S8 1.30 0.58 2.40 2.06 n 5 3 5 4 6 4

...................................................... Total N=27

D a t a Set 3

__-____---__-_--_-------------------------------------- CONTROL DISTRACTION 1MAG.INVOLVEMENT

Y o u n g Old Y o u n g Old Y o u n g Old BSSSLLYS .............................................. NURSE 11.00 11.67 13.20 11.00 11.00 9.75 s.d. 3.81 2.89

DOCTOR 9.20 10.33 s. d. 2.59 3.51

PARENT 10.40 10.33 s.d. 3.44 4.51

RATER1 10.40 9.00 s.d. 3.21 3.00

RATER1 10.40 10.67 s.d. 3.36 3.06

n 5 3 EfRSIJ!!lERVENILON ------- NURSE 9;40 10.00 s.d. 2.79 1.73

DOCTOR 8-60 9.67 s-d. 3.36 3.06

PARENT 8.20 9.33 5.d. 2.17 2.52

RATER1 8.80 8.00 s.d. 2.35 2.65

RATER2 9.40 7.67 s.d. 2.30 0.58 n 5 3

5.d. DOCTOR s.d.

PESRENT 5. d.

RESTER1 s. d.

RATER2 s.d. n

Total N=27

GPPENDIX J Results . f rom. the LP Procedure

Data Set k

RATER 1. .....................................................

CONTROL DISTRACTION 1MAG.INVOLVEMENT Young Old Young Old Young Old

..................................................... Basel. mean 10.14 4.40 16.29 9.67 12.50 10.50

5.d. 6.96 2.30 4.03 6.77 9.14 8.23 n 7 5 7 6 S 4

Int.1 mean 8.43 5.40 12.00 5.b7 9.75 8.00 s.d. 6.34 4.39 6.~53 5.39 5.70 5.88

n 7 5 7 6 8 4

RATER 2.

Young Old Young Old Young Old ..................................................... Basel. mean 9.85 5.00 14.71 8.67 13.00 9.25

s.d. 6.38 2.12 4-92 6.&2 5.32 7.37 n 7 5 7 6 8 4

..................................................... 1nt.I mean 8.57 4.60 11.57 4.67 8.63 5.75

s.d. 5.38 3.65 6.13 4.63 5.18 4.19 n 7 5 7 6 8 4

Total N=37

Results from the LP Pracedure Data Set A

Anal ysi s of Covari ance of PBRS-H scares ---- .................................. Source Sum of d f . Mean F P-

Squares Square

R a t e r s 9.38 1 9.38 7.95 -01 R X G S.4& L 2-73 2.31 . 12 C\

R X A 3-20 1 3-20 2.71 - 1 1 R X G X f i 0.21 2 0.10 0.09 -92 Basel i ne 2.09 1 2.09 1.77 - 1 9 Error 35.41 3 3 1.18

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