Debra Fanurik

The relationship between children's coping styles and psychological interventions for cold pressor pain

&NA; This study examined the hypothesis that matching pain management interventions to childrens preferred coping methods would increase pain tolerance and decrease self‐reported pain during the cold pressor pain paradigm. Children aged 8–10 years were classified as ‘attenders’ (focusing on the stimulus) or ‘distractors’ (focusing away from the stimulus) based upon their spontaneous coping responses during a baseline exposure to the cold pressor. Children were then randomly assigned to 1 of 3 intervention conditions (sensory focusing, imagery, or no intervention) and completed the cold pressor procedure again 2 weeks later. A significant interaction was found between coping style and intervention. Children who were classified as distractors demonstrated greater tolerance when taught to use imagery techniques (a ‘matched’ intervention). Although pain ratings tended to be lower for distractors using imagery, the significant interaction resulted from an increase in ratings for the distractors using sensory focusing (i.e., a ‘mismatched’ intervention). Results suggest that, for distractors, interventions that are consistent with natural coping methods are most effective in enhancing abilities to cope with pain, while a mismatched intervention reduces coping abilities. The findings also suggest further study regarding how to provide effective pain intervention with attenders, since neither intervention enhanced coping in this group.

Pain assessment in children with cognitive impairment. An exploration of self-report skills.

Prior to surgery, 47 children (ages 8 to 17) with borderline to profound cognitive impairment were administered tasks to evaluate their understanding of the concepts of magnitude and ordinal position and their abilities to use a 0 to 5 numerical scale to rate pain levels in schematic faces. Of the 111 children (ages 4 to 14) without cognitive impairment, were administered the same tasks. Nurses conducting preoperative evaluations predicted whether children would understand the numerical scale. Fifty percent (= 3) of children with borderline and 35% (n = 7) of children with mild cognitive impairment (and all children 8 years and older nonimpaired) correctly used the scale. Half of the children with cognitive impairment demonstrated skills (magnitude and ordinal position) that may allow them to use simpler pain rating methods. Nurses overestimated the abilities of cognitively impaired children (and younger children without cognitive impairment) to use the rating scale.

Children with cognitive impairment: parent report of pain and coping.

Information about pain in children with cognitive impairment is lacking. To gather pain-relevant information in this population, parents of 145 children with borderline to profound cognitive impairment were interviewed regarding their childrens pain expression, experience, treatment, and coping behavior. Descriptions of pain expression and coping behavior were associated with the level of cognitive impairment. Children with mild to moderate cognitive impairment were more likely to be described as directly communicating their pain and exhibiting procedural coping strategies similar to those observed in children without cognitive impairments. More than half of the parents reported that their children experienced pain differently than did children without cognitive impairment, with the majority perceiving decreased pain sensitivity and greater pain tolerance. Finally, one third of parents felt that their childrens pain was treated differently than that of other children. Half of these parents believed that health care providers had difficulties assessing and treating their childrens pain. Results contribute to the developing foundation of information about pain in this special pediatric population.

The cold pressor pain paradigm in children: feasibility of an intervention model (Part II).

&NA; The purpose of this study was to examine the feasibility of testing a psychological approach (hypnosis) to pain reduction in children using the cold pressor paradigm. Childrens pain ratings at 10 sec intervals and duration of arm immersion (40 sec maximum) in 15 °C (n = 37) and 12 °C water (n = 29) were assessed in 6–12‐year‐old children during 2 baseline trials (alternating arms), followed by 2 more trials after randomization to a control or hypnosis treatment condition. Hypnosis was found to reduce pain significantly more than the control condition in both 15 °C and 12 °C water. Hypnotic susceptibility was not strongly related to hypnotic pain reduction. However, age was significant, with younger children showing higher pain ratings and early arm withdrawal rates and less response to hypnosis than older children. In 15 °C water, females had higher pain ratings and early withdrawal rates than males, but this sex discrepancy disappeared in 12 °C water. This study demonstrated the feasibility of the cold pressor paradigm for testing intervention strategies and its potential for enhancing our understanding of pain in children.

An investigation of cold pressor pain in children (part I)

&NA; Although the cold pressor model of pain has been used widely in laboratory studies with adults, it has been rarely used to study pain in children, likely because of obvious ethical concerns about the well‐being of child participants. The goals of the present investigation were to determinel (1) whether a laboratory study of this type could be conducted in a way that children would find interesting and non‐threatening, and (2) whether potentially useful data could be gathered systematically within the framework of such a study. Results of a pilot study in children 6–12 years, with water temperature at 15°C (n = 37) and 12°C (n = 29), indicated that useful data could be obtained from this paradigm. Childrens pain ratings increased with duration of arm immersion in the water and with decreasing water temperature. Most importantly, children and their parents perceived the format to be interesting and non‐stressful. Continued caution and improved techniques for monitoring the well‐being of child participants need to be a part of any future investigations of this type.

Analgesia following surgery in children with and without cognitive impairment

Abstract Both children and adults with cognitive impairment (CI) have historically been excluded from research examining pain. This is unfortunate since patients with CI may be at higher risk for experiencing pain or having their pain undertreated due to the difficulty of pain assessment and communication. There are now several published reports about the general pain experience of both adult and pediatric patients with cognitive impairment. The purpose of this study was to compare the amount and type of pain medication administered in children with and without CI after surgery to ascertain if there were any differences in analgesic administration patterns between these two groups. One hundred and fifty‐two children with borderline to profound CI and 138 non impaired (NI) children were recruited to participate. Analgesic administration data include type and amount of opioid, type of non‐opioid medication, and prescribed discharge medications. Results of this study show that children with CI undergoing surgery received less opioid in the perioperative period than children without CI. However, children with CI received comparable amounts and types of analgesics in the postoperative period as children without CI.

Efficacy of Parental Application of Eutectic Mixture of Local Anesthetics for Intravenous Insertion

Objective. To demonstrate that parent application of eutectic mixture of local anesthetics (EMLA) results in equal reduction of the pain of intravenous (IV) placement compared with clinician application of EMLA, and to assess potential difficulties with parental application. Study Design. A 2 × 2 randomized block design was used, with 41 children divided into two age groups (5–12 years vs 13–18 years) and randomized to one of two experimental groups (parent-applied EMLA vs clinician-applied EMLA). Methods. All children were scheduled to have outpatient gastrointestinal endoscopies with IV sedation. EMLA was placed at least 60 minutes before IV insertion either by the parent or a clinician, depending on the experimental group assignment. Outcome measures were child pain ratings and observed behavioral distress ratings. Parents and children were interviewed to determine parent and child anxiety levels in anticipation of the IV insertion, previous needle stick experience, and previous difficulty coping. Feasibility outcomes included technical difficulty with application of EMLA and appearance of the EMLA cream and occlusive covering. Results. Pain ratings and behavioral distress ratings were generally in the low to moderate range for all groups and were consistent with previous empiric reports of EMLA outcome. There were no significant differences in pain or distress ratings for either the age or the experimental groups. Parent ratings of their childs previous difficulty coping was related to the level of behavioral distress exhibited before (r = .50), during (r = .32) and after (r = .44) the IV insertion. In addition, childrens anxiety ratings about IV insertion seemed to differ among groups (although not statistically significant for post hoc comparisons), with the most anxiety reported by the younger children when clinicians applied the EMLA and by older children when parents applied the EMLA. Conclusion. Parent application of EMLA appears to be as effective as clinician application in reducing childrens pain and distress associated with IV insertion. Permitting parents to apply the EMLA at home can allow children who are having procedures on an outpatient basis to benefit from topical anesthesia without having to arrive early to the clinic or hospital. Additionally, application by parents may result in less anticipatory anxiety for younger children.

A COMMUNITY PROGRAM TO REWARD CHILDREN'S USE OF SEAT BELTS

This paper reports on a community-wide effort to increase elementary school childrens use of seat belts. Twenty-five schools serving over 9,000 children participated in a program of rewards (stickers, bumper strips, and chances on pizza dinners) administered by parent-teacher organization volunteers. Comprehensive observations were made at three representative schools. Categorization of compliance with safety rules required all passengers to be buckled into safety devices before the children received the rewards. The rewards, on average across schools, increased compliance from baseline of 18.1% to 62.4% during the interventions. Withdrawal of the rewards resulted in a decrease to 49% compliance, but this rate remained above baseline. The involvement of community groups and institutions in this safety program is highlighted.

Rewarding elementary schoolchildren for their use of safety belts.

This study reports on the application of reward procedures to elementary schoolchildren to increase their use of seat belts en route to two schools. Following strict rules for assessing buckle-up compliance, all passengers in a car had to be safely secured in order for the schoolchildren to receive rewards. Compliant children received paper slips as they arrived at schools, which were redeemable for stickers, bumper stickers, and coloring books. The slips were also used in weekly drawings for pizza dinners. The mean compliance rate for School 1 was 4.3% during baseline, 66.2% for the reward phase across 4 weeks, 60% for return to baseline, 17.2% for Follow-Up 1, and 8.5% for Follow-Up 2. For School 2, the mean percentage was 5.3% at baseline, 69.8% for the reward phase, 68.5% for return to baseline, 40.1% for Follow-Up 1, and 20% for Follow-Up 2. These results indicate that rewarding the schoolchildren increased their own seat-belt use as well as that of their adult drivers and other passengers. Decreases in usage were observed after the rewards were removed.

Long-Term Effects of a Brief Distraction Intervention on Children’s Laboratory Pain Reactivity

This 2-year follow-up study examined the effects of a brief behavioral intervention on task-based coping and pain reactivity to the cold pressor task (CPT). In the original study by Fanurik et al. (1993), 64 children (aged 8 to 10) whose coping style was categorized as “attender” or “distracter,” based on primary coping strategy during baseline CPT trials, received a 5-minute intervention (attention-focusing, distraction training, or control, randomly assigned). In the present study, 51 (32 female) of the original sample were readministered the CPT, and their coping style and pain responsivity were reassessed. Both distracters and attenders given distraction training preferred use of distraction at follow-up. The distraction training group also demonstrated greater tolerance at follow-up compared to controls, although pain ratings did not differ by intervention group. Our findings suggest that a brief distraction intervention has long-term effects on task-based coping and experimental pain reactivity.