Ronald L. Blount

Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial.

Background:Children and parents experience significant anxiety and distress during the preoperative period. Currently available interventions are having limited efficacy. Based on an integration of the literature in both the anesthesia and psychological milieus, the authors developed a behaviorally oriented perioperative preparation program for children undergoing surgery that targets the family as a whole. Methods:Children and their parents (n = 408) were randomly assigned to one of four groups: (1) control: received standard of care; (2) parental presence: received standard parental presence during induction of anesthesia; (3) ADVANCE: received family-centered behavioral preparation; and (4) oral midazolam. The authors assessed the effect of group assignment on preoperative anxiety levels and postoperative outcomes such as analgesic consumption and emergence delirium. Results:Parents and children in the ADVANCE group exhibited significantly lower anxiety in the holding area as compared with all three other groups (34.4 ± 16 vs. 39.7 ± 15; P = 0.007) and were less anxious during induction of anesthesia as compared with the control and parental presence groups (44.9 ± 22 vs. 51.6 ± 25 and 53.6 ± 25, respectively; P = 0.006). Anxiety and compliance during induction of anesthesia was similar for children in both the ADVANCE and midazolam groups (44.9 ± 22 vs. 42.9 ± 24; P = 0.904). Children in the ADVANCE group exhibited a lower incidence of emergence delirium after surgery (P = 0.038), required significantly less analgesia in the recovery room (P = 0.016), and were discharged from the recovery room earlier (P = 0.04) as compared with children in the three other groups. Conclusion:The family-centered preoperative ADVANCE preparation program is effective in the reduction of preoperative anxiety and improvement in postoperative outcomes.

Training children to cope and parents to coach themduring routine immunizations: Effects on child, parent, and staff behaviors*

Preschool children (n=30) undergoing routine immunizations at a health department were taught to use distraction prior to the medical procedure and to use a party blower, as an age appropriate version of deep breathing, just prior to and during the injection. Parents were taught to coach their children. A no-treatment control group (n=30) was used to evaluate effectiveness. Results indicated that trained parents engaged in more prompting of their child to use the blower than untrained parents. Trained children engaged in more blower usage than untrained children. Child distress was lower on two of three observational measures for the trained children. Parents of trained children reported that both they and their children were less distressed when compared to how they normally would be during the procedures. Staff, who were not trained nor instructed to change their behavior, engaged in significantly more coaching of trained than of untrained children to use the blower, suggesting generalization of the behavior from parents to staff. Suggestions for future research are included.

Pediatric procedural pain.

This article reviews the various settings in which infants, children, and adolescents experience pain during acute medical procedures and issues related to referral of children to pain management teams. In addition, self-report, reports by others, physiological monitoring, and direct observation methods of assessment of pain and related constructs are discussed and recommendations are provided. Pharmacological, other medical approaches, and empirically supported cognitive behavioral interventions are reviewed. Salient features of the interventions are discussed, and recommendations are made for necessary components of effective treatment interventions.

Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations.

This study compared distraction, an anesthetic (eutectic mixture of local anesthetics [EMLA]), and typical care during pediatric immunizations. Participants were 39 4th graders receiving a 3-injection vaccination series over a 6-month period. Children displayed low distress despite reporting moderate anxiety and pain. Distraction resulted in more nurse coaching and child coping and less child distress than did EMLA or typical care on an observational measure. EMLA did not result in increased child coping or decreased distress. In fact, the nurse coached more, and trends suggested that children coped more with typical care than with EMLA. Whereas participant ratings and heart rate did not differ among conditions, all 3 conditions demonstrated improvements over time with these measures. Satisfaction ratings suggested that children preferred the treatments to typical care, whereas the nurse appreciated aspects of each of the conditions. Finally, distraction was more economical than EMLA.

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.

Association of Disease, Adolescent, and Family Factors with Medication Adherence in Pediatric Inflammatory Bowel Disease

OBJECTIVE To examine factors associated with adolescent and parent-reported adherence to prescription and over-the-counter (OTC) medications in a cross-sectional sample of youth with inflammatory bowel disease (IBD). METHOD Ninety adolescents and their parents completed measures of medication adherence and disease, individual, and family factors while attending an outpatient gastroenterology appointment. RESULTS Longer time since diagnosis, greater perceived disease severity, and a lack of autonomous motivation to adhere predicted adolescent report of lower adherence to prescription medications. Similarly, longer time since diagnosis predicted adolescent report of lower adherence to OTC medications. Less time since diagnosis, greater maternal involvement in the medical regimen, higher perceived disease severity, and less perceived conflict predicted better parent-reported adherence to OTC medications. CONCLUSIONS Interventions for improving adherence in adolescents with IBD should address disease, individual, and family factors with special attention given to adolescents who have been diagnosed longer.

Parent and patient perspectives on barriers to medication adherence in adolescent transplant recipients.

Abstract:  The aim of this study was to identify barriers to medication adherence in adolescent transplant recipients. Eighty adolescent transplant recipient families reported in an open‐ended manner about barriers to medication adherence. These responses were then coded to reflect potentially important themes associated with medication adherence. The themes derived included: forgot/distracted, poor planning/scheduling issues, physical barriers/medication issues, and voluntary resistance/attempts to be normal. Inter‐rater reliability for barrier coding was very high (k = 0.91). Patients who were classified as non‐adherent reported significantly more overall barriers, more forgot/distracted barriers, and more voluntary resistance/attempts to be normal barriers than those classified as adherent. Non‐adherence was also found to be more likely when adolescents, as opposed to parents, were responsible for administering the medication. Further, non‐adherence was more likely when taking morning rather than evening doses. These findings are explained with an emphasis on potential remedies that directly address the stated barriers.

Healthcare Provider and Parent Behavior and Children's Coping and Distress at Anesthesia Induction

Background:To date, no study has evaluated the impact of specific healthcare provider and parent behaviors on children’s distress and coping during anesthesia induction. Method:Extensive digital video data were collected on 293 two- to ten-yr-old children undergoing anesthesia induction with a parent present. Anesthesiologist, nurse, and parent behavior and children’s distress and coping were coded using the Revised Preoperative Child–Adult Medical Procedure Interaction Scale administered using specialized coding software. Results:Anesthesiologists and parents engaged in higher rates of most behaviors than nurses. Overall, adult emotion-focused behavior such as empathy and reassurance was significantly positively related to children’s distress and negatively related to children’s coping behaviors. Adult distracting behavior such as humor and distracting talk showed the opposite pattern. Medical reinterpretation by anesthesiologists was significantly positively related to children’s coping behaviors, but the same behavior by parents was significantly positively related to children’s distress. Conclusions:The data presented here provide evidence for a relation between adult behaviors and children’s distress and coping at anesthesia induction. These behaviors are trainable, and hence it is possible to test whether modifying physician behavior can influence child behavior in future studies.

Analysing a family-centred preoperative intervention programme: a dismantling approach

BACKGROUND The goal of this project was to identify key effective components of ADVANCE, a family-centred preoperative intervention programme, through the use of a dismantling approach. ADVANCE was previously demonstrated to be more effective than parental presence and just as effective as midazolam in reducing childrens preoperative anxiety. The total programme, however, may be difficult to implement in hospitals across the country. METHODS Subjects in this follow-up dismantling report were 96 children aged 2-10 who were part of the original study and who underwent anaesthesia and surgery. Baseline characteristics, parental adherence to the components of ADVANCE, and child and parent anxiety were assessed. RESULTS We found that greater parental adherence to the ADVANCE intervention was associated with lower child anxiety before surgery. The two components of ADVANCE that emerged as having a significant impact on childrens anxiety were practising with the anaesthesia mask at home and parental planning and use of distraction in the preoperative holding area. In fact, not only did children experience significantly less preoperative anxiety when their parents were adherent to mask practise and use of distraction, their anxiety tended to remain stable and relatively low throughout the preoperative period. CONCLUSIONS Shaping and exposure (i.e. practise with the anaesthesia mask) and parental use of distraction in the surgical setting are two beneficial components that could be included in preoperative preparation programmes that will be designed in the future.

Bridging the Gap between Explicative and Treatment Research: A Model and Practical Implications

The recent move toward the recognition of empirically supported treatments (ESTs) within numerous facets of the field of clinical psychology has been met with general enthusiasm. The EST movement would not have been possible without the efforts of earlier treatment researchers. Paradoxically, this is also a time when some of the leaders in clinical psychology are recognizing that there is a paucity of experimental treatment research being conducted today relative to the high volume of correlationally based, explicative research, which examines the associations among variables. In this paper we present numerous reasons for the relative excess of explicative research and the paucity of treatment outcome research. Clinical practice is used to exemplify how assessment-oriented, explicative activities and the design of treatment can be integrated. A research-based example in which explicative research is used directly to inform the design of the intervention in treatment outcome research is presented as one model for emulation. Specific recommendations are made to help guide professionals and students entering the field who wish to conduct treatment research. An expansion on some of the themes highlighted in this paper can be found in the chapter from which it was in part derived (Blount, Bunke, & Zaff, 1999).