Dennis C. Russo

Patient-controlled analgesia in children and adolescents: A randomized, prospective comparison with intramuscular administration of morphine for postoperative analgesia

A randomized, prospective trial of patient-controlled analgesia (PCA), that is, a method of analgesia administration involving a computer-driven pump activated by patients to receive small doses within defined limits was performed in 82 children and adolescents after major orthopedic surgery to compare (1) intramuscularly administered morphine, (2) PCA morphine and (3) PCA morphine with a low-dose continuous morphine infusion (PCA-plus). Patients receiving PCA and PCA-plus had lower pain scores and greater satisfaction than patients receiving intramuscularly administered morphine. The three groups used equal amounts of morphine and most measures of recovery were identical in the groups. In particular, PCA and PCA-plus did not increase the incidence of opioid-related complications, and patients receiving PCA-plus were less sedated than patients receiving intramuscular therapy. We conclude that PCA and PCA-plus are safe and effective methods of pain relief in children and adolescents after orthopedic surgery, are better accepted than intramuscular injections, and do not increase perioperative morbidity.

Behavioral Approaches to the Management of Chronic Pain in Children

This article focuses on the basic premises underlying the behavioral assessment and treatment of chronic pain, particularly as they apply to the less distinct pain disorders of childhood, such as obscure headache and abdominal pain. Pain behavior management procedures, relaxation techniques, and biofeedback training are discussed in detail in reviewing recent research developments in this area.

Compliance and Correlated Problem Behavior in Children: Effects of Contingent and Noncontingent Reinforcement.

Analyses of response relationships offer the potential for designing treatment procedures that are more economical and entail less risk for misuse than many we currently employ. The present study investigated whether previous results indicating the reduction of problem behaviors by reinforcing compliance in fact occurred because of the contingent relationship between compliance and the presumed reinforcing events. A clinic analogue procedure consisting of a standard set of adult requests was employed in a multiple baseline design across subjects with three children receiving three conditions — no reinforcement, noncontingent reinforcement, and reinforcement contingent on compliance — and a fourth child receiving the first and third conditions to assess possible order effects. The data indicated that: (1) compliance covaried inversely with some, but not all, of the problem behaviors measured; (2) sustained covariation occurred only when reinforcement was contingent on compliance; (3) substantially large but transient increases in compliance and decreases in problem behavior during noncontingent reinforcement occurred for those children who initially demonstrated high compliance and low levels of aberrant behavior during baseline; and (4) the problem behaviors that inversely covaried with compliance were idiosyncratic across children. The results suggest that treatment procedures based on response relationship strategies should consider that childrens individual learning histories may determine which behaviors covary and the likelihood that large, initial changes can occur with noncontingent reinforcement.

Behavioral Treatment of Pica in Children with Lead Poisoning

Lead poisoning, a serious problem that can result in permanent neurological damage, often results from the ingestion of inedible substances that contain lead. The behavior of ingesting nonedible substances in termed pica. In this study, behavior modification procedures were used to eliminate pica in three young children with lead poisoning. Three kinds of procedures were used: (1) discriminate training, in which the subject was taught to recognize that paint and several objects were not edible; (2) reinforcement for the absence of pica; and (3) overcorrection for the occurence of pica. Pica was eliminated in all three subjects. While it was not always clear which component of the treatment was responsible for the decrease, the sequence used had the advantage of an effictive clinical technique proceeding from least to progressively more restrictive procedures.

Educational Intervention for Children With Epilepsy: A Challenge for Collaborative Service Delivery:

A new approach to educational intervention that establishes open communication and collaboration between medical and school personnel is required if the special needs of children with epilepsy are to be met. Seizures and anticonvulsant medications have an impact upon classroom performance, but the effect of learning and behavior problems associated with epilepsy is often more severe. Comprehensive managment of epilepsy demands treatment of both medical and educational problems. Lack of information regarding epilepsy, its management, and associated disorders, however, prevents teachers from providing appropriate educational interventions. An epilepsy training program for school personnel is proposed as necessary for a multidisciplinary approach to treatment of children with epilepsy.

Behavioral medicine with the developmentally disabled

The application of behavioral medicine to the developmentally disabled has a short history, presently characterized by underachievement, and (so like an underachiever!) a brilliant future. We will briefly review here the origins, current status, and the future of this important and growing field.

Behavioral interventions and stress management training for hospitalized adolescents and young adults with cystic fibrosis.

Recent studies have demonstrated that the majority of cystic fibrosis (CF) patients are not at high risk for developing psychological problems. Clinical studies emphasizing the development of adaptive coping mechanisms in these patients have been suggested as a more appropriate line of research. The purpose of the present paper is to describe our experience in teaching various behavioral and stress management strategies to help CF patients. Behavioral counseling, relaxation training, and biofeedback have all been used with these patients to help them manage a number of problems more effectively. The predominant presenting problems have included elevated anxiety levels, sleeping difficulties, pain, and hyperventilation episodes. The typical treatment course with these patients is described and a case example is given to help elucidate the nature of behavioral interventions. Patient satisfaction ratings indicate that most patients view these techniques positively. Clinical observations suggest that the acquisition of behavioral coping skills may enhance the CF patients perceived control of his/her situation, reduce the level of pain and anxiety, and enhance the quality of life.

A requiem for the passing of the three-term contingency

Recent experimental work suggests that the operant model of behavior change is limited in its ability to provide a convincing explanation of resulting data. Similar deficiencies are seen as well in uni-factor behavior therapy or cognitive models. Indeed, the “drift” of behavior therapy toward dual-factor explanatory models has arisen primarily as a way to explain such research outcomes. This paper traces the development of behavior therapy in light of these issues and with respect to additional data which suggests strong interrelationships between behavioral, cognitive, and physiological domains. It is argued that multiple factors must be taken into account in both research and clinical endeavors and that behavior therapy will remain a significant and central approach in managing human problems.

Some New Dimensions of Behaviour Analysis and Therapy

Clinical approaches based on the principles of behaviour modification and behaviour therapy have evolved into an experimental literature that demonstrates the benefit and efficacy of these approaches in mental illness, mental retardation, autism, and special education. Significant advantages of these learning-based therapies have reduced reliance on traditional psychodynamic models. Indeed, over the past 30 years, behavioural services have not only become a cornerstone of clinical psychology but have led to the development of new models of care for a host of other disorders and problems. This paper summarizes the historical perspectives and new directions in the field of behaviour analysis and therapy. Focusing on applications to paediatric medicine, we will trace the development of behavioural applications in this field and explore new extensions of the behavioural paradigm. By way of review of one of the newest areas of endeavour for behavioural medicine, traumatic brain injuries, we suggest future directions for the growth of behavioural approaches.

Families of children with traumatic injuries identify needs for research and training

This paper summarizes the survey responses of 67 families with children who were hospitalized after traumatic injuries. The survey was conducted during the pre-planning phase of a major research proposal on the rehabilitation of children who had been injured. The purpose of the survey was to involve families in the identification of needs and determination of priorities for research and training in childhood injuries. The first part of the survey focused on direct services that children and their families received through medical, psychosocial, educational and vocational interventions and providers. The second part concerned the immediate and long-term effects of a childs injury upon the family. Families were asked to indicate: (1) the direct care services they considered most important in their childs recovery; (2) areas needing more research and study; (3) training needed by professionals; and (4) information needed by families. Major findings were the importance to families of emergency room treatment and the quality of hospital care; concerns about communication between professionals and parents; the uncertainty of expectations for the future; and lack of information on community resources. Written comments emphasized the emotional impact of physical trauma upon families and the need for longitudinal research, with pediatric rehabilitation viewed as a broad spectrum of care starting with emergency room care and hospitalization and continuing through school and community programs. As a result of this survey several projects were initiated. They include: revision of head sheets distributed by emergency rooms, physician training in communication skills, preparation of families as service coordinators, and development of materials and programs specifically for families.