Psychological treatment of distress, pain and anxiety for...
Transcript of Psychological treatment of distress, pain and anxiety for...
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 [email protected])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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