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| Behavior Analysis Contributions to Managing Pediatric Pain |
| Tuesday, May 30, 2006 |
| 9:00 AM–10:20 AM |
| Baker |
| Area: CBM; Domain: Service Delivery |
| Chair: Keith J. Slifer (Kennedy Krieger Institute) |
| Abstract: Over last 25 years, behavior analysts have used their skills to address the many challenges that children with medical conditions and/or developmental disabilities experience in hospitals and other medical settings. Behavioral interventions have been shown effective for increasing child cooperation with medical procedures and regimens. They also have been used to teach specific child and parent skills needed for maintaining optimal health and quality of life. One of the most challenging problems encountered by medical and rehabilitation professionals is the management of children’s medically related pain and anxiety. This symposium will focus on some recent applications of behavioral interventions for managing acute medical procedure or rehabilitation associated pain and distress in pediatric patients. Four presentations will be made covering the following topics: (1) counter-conditioning to reduce distress and increase compliance during venipuncture, (2) a critical review of studies using distraction interventions for immunization pain, (3) distraction intervention for infant immunization pain, and (4) pain management techniques used with pediatric rehabilitation patients’ after orthopedic surgery. The common characteristics of each of these applications will be discussed as well as their unique challenges and directions for future research. |
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| Using Counter-Conditioning to Reduce Distress and Increase Compliance with Venipuncture for Patients with Developmental Disabilities. |
| LANA L. HARDER (Kennedy Krieger Institute/Johns Hopkins University School of Medicine), Melissa H. Beck (Kennedy Krieger Institute/Johns Hopkins University School of Medicine), Keith J. Slifer (Kennedy Krieger Institute/Johns Hopkins University School of Medicine) |
| Abstract: Children must sometimes tolerate aversive medical procedures to benefit from prescribed medical care. These procedures occur more frequently for children with disabilities because of associated medical conditions. Procedures requiring venipuncture typically produce acute pain. Undergoing such procedures often results in conditioned anxiety and avoidant behaviors (e.g., aggression, escape, verbal refusal), which interfere with the safe performance of medical care. Avoidant behaviors may develop by a process of aversive conditioning when children experience repeated exposure to painful stimulation. Data for three male patients ages 5, 13 and 16 years diagnosed with Autism will be presented. Prior to treatment, all three patients exhibited avoidant behaviors that prevented their participation in medical care. Weekly outpatient treatment sessions were conducted to counter-condition the patients’ behavioral distress when encountering stimuli associated with venipuncture. Distraction and positive reinforcement were implemented to help these patients relax during graduated mock venipunctures. The patients exhibited reduced behavioral distress during treatment sessions relative to baseline, and two of three patients successfully completed all required actual venipunctures. Results will be discussed in relationship to conditioning and counter-conditioning processes. Factors that facilitate and prevent the generalization of treatment effects also will be discussed. |
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| A Critical Review of Distraction Interventions for Pain Management during Pediatric Immunizations. |
| MELISSA ANN DEMORE (West Virginia University, Kennedy Krieger Institute, and Johns Hopkins University School of Medicine), Lindsey Cohen (Georgia State University) |
| Abstract: Immunizations are the most common painful medical event of childhood, with children receiving roughly 25 needles by their 6th birthday. Immunization pain has clear immediate and lasting negative effects on the child, parent, and staff. A variety of behavioral interventions have been evaluated for immunization pain, and distraction is a common ingredient. The current study provides a review and critique of distraction interventions for pediatric immunization pain. Review inclusion criteria found fifteen studies that employed an experimental evaluation of distraction for children’s immunization pain. The studies found fairly consistent reductions on behavioral observational measures of pain, and less consistent results on self-report or physiological indices. Most interventions were relatively time-effective; ranging in time requirements of 5 to 15 minutes. A cost analysis revealed that the most economical distraction interventions were music and the most expensive were televised movies. Nearly half of the studies exhibited a moderate effect size on at least one measure of pain. Chi square analyses revealed that interventions that required an overt behavioral response of the child, engaged multiple sensory modalities, and were uniformly presented to all children were more likely to obtain an effect size of at least moderate magnitude. Conclusions and future directions are discussed. |
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| Distraction for Infant Immunization Pain. |
| LINDSEY COHEN (Georgia State University), Jill MacLaren (Brown University), Beverly Fortson (Medical University of South Carolina), Abby Friedman (West Virginia University), Melissa Ann DeMore (Kennedy Krieger Institute/Johns Hopkins University School of Medicine), Crystal S. Lim (Georgia State University), Elisabeth Shelton (West Virginia University), Balram Gangaram (University of Hawaii) |
| Abstract: Distraction has been shown to be an effective technique for managing pain in children. However, few investigations have been conducted on the efficacy of distraction for infants’ pain management. The current study examined the effectiveness of a nurse-implemented distraction intervention in reducing infants’ distress during immunizations. Participants consisted of 136 infants receiving routine vaccinations and their caregivers. Measures included parent-report, nurse-report, and a behavior observational scale. Although nurses in the distraction group did not perform significantly more distracting behavior than nurses in the control group, parents in the distraction group did exhibit higher rates of distraction than those in the control group. In terms of treatment effects, infants in the distraction group displayed fewer distress behaviors than infants in the control group, prior to and during recovery from the injection. Thus, distress reduction may have resulted from distracting qualities of the movies and/or parent coaching behavior. In terms of phase variations, infants in the control condition exhibited more distress following the injection, than during the actual procedure, suggesting a slow recovery from the injection. Infants in the distraction condition, however, exhibited less distress following the injection, indicating that distraction is particularly helpful in return to baseline functioning. |
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| Pain Management Techniques to Increase Pediatric Rehabilitation Patients’ Compliance with Physical Demands After Orthopedic Surgery. |
| MELISSA A. MEYERS (Kennedy Krieger Institute/Johns Hopkins University School of Medicine), Robin Anne Frutchey (Kennedy Krieger Institute/Johns Hopkins University School of Medicine), Melissa Ann DeMore (Kennedy Krieger Institute/Johns Hopkins University School of Medicine) |
| Abstract: Patients may exhibit high levels of distress during physical rehabilitation after orthopedic surgery. Distress behaviors interfere with the achievement of optimal therapy gains. Distress behaviors may be due to pain exacerbated by physical demands, conditioned anxiety, lack of patient skills to manage pain and anxiety, and/or a loss of environmental predictability. The efficacy of behavioral pain management techniques for decreasing distress and increasing compliance with physical demands will be presented for three patients (ages 6, 14, and 20 years) who were admitted for physical rehabilitation following orthopedic surgery. Patients presented with distress vocalizations, self-reports of frequent and intense pain, physical discomfort behaviors, and noncompliance with therapeutic task demands. During their hospitalization, the patients were provided with individualized assessment and intervention to increase compliance with physical demands, decrease inappropriate distress vocalizations, decrease physical discomfort behaviors, and decrease the frequency and intensity of self-reported pain. Clinically significant gains were achieved in each case by an individualized approach to behavioral distress management using one or more of the following strategies: distraction, guided imagery, deep breathing, education, differential reinforcement, and antecedent management. Results are discussed in the context of the pediatric pain management literature and directions for future research. |
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