EMDR and Nonpharmacological Techniques for Anxiety Prevention in Children Prior to Invasive Medical Procedures: A Randomized Controlled Trial

Nonpharmacological Techniques (NPT) have been suggested as an efficient and safe means to reduce pain and anxiety in invasive medical procedures. Due to the anxious and potentially traumatic nature of these procedures, we decided to integrate an eye movement desensitization and reprocessing (EMDR) session in the preprocedure NPT. The main purpose of this study was to evaluate the efficacy of one session of EMDR in addition to the routine NPT. Forty-nine pediatric patients (Male = 25; Female = 24) aged 8–18 years (M = 13.17; SD = 2.98) undergoing painful and invasive medical procedures were randomized to receive standard preprocedural care (N = 25) or a session of EMDR in addition to the standard nonpharmacological interventions (N = 24). Participants completed the anxiety and depression scales from the Italian Psychiatric Self-evaluation Scale for Children and Adolescents (SAFA) and rated anxiety on a 0–10 numeric rating scale. Participants in the NPT+EMDR condition expressed significantly less anxiety before the medical procedure than those in the NPT group (p = .038). The integration of EMDR with NPT was demonstrated to be an effective anxiety prevention technique for pediatric sedo-analgesia. These results are the first data on the efficacy of EMDR as a technique to prevent anxiety in pediatric sedo-analgesia. There are important long-term clinical implications because this therapy allows an intervention on situations at risk of future morbidity and the prevention of severe disorders.

Kids' Perceptions toward Children's Ward Healing Environments: A Case Study of Taiwan University Children's Hospital

This paper summarizes the opinions of experts who participated in designing the environment of a children's hospital and reports the results of a questionnaire survey conducted among hospital users. The grounded theory method was adopted to analyze 292 concepts, 79 open codes, 25 axial codes, and 4 selective codes; in addition, confirmatory factor analysis and reliability analysis were performed to identify elements for designing a healing environment in a children's hospital, and 21 elements from 4 dimensions, namely, emotions, space design, interpersonal interaction, and pleasant surroundings, were determined. Subsequently, this study examined the perceptions of 401 children at National Taiwan University Children's Hospital. The results revealed that, regarding the children's responses to the four dimensions and their overall perception, younger children accepted the healing environment to a significantly higher degree than did older children. The sex effect was significant for the space design dimension, and it was not significant for the other dimensions.

Effects of Distraction on Pain, Fear, and Distress During Venous Port Access and Venipuncture in Children and Adolescents With Cancer

This study evaluates the effect of self-selected distracters (ie, bubbles, I Spy: Super Challenger book, music table, virtual reality glasses, or handheld video games) on pain, fear, and distress in 50 children and adolescents with cancer, ages 5 to 18, with port access or venipuncture. Using an intervention-comparison group design, participants were randomized to the comparison group (n = 28) to receive standard care or intervention group (n = 22) to receive distraction plus standard care. All participants rated their pain and fear, parents rated participant fear, and the nurse rated participant fear and distress at 3 points in time: before, during, and after port access or venipuncture. Results show that self-reported pain and fear were significantly correlated (P = .01) within treatment groups but not significantly different between groups. Intervention participants demonstrated significantly less fear (P <.001) and distress (P = .03) as rated by the nurse and approached significantly less fear (P = .07) as rated by the parent. All intervention parents said the needlestick was better because of the distracter. The authors conclude that distraction has the potential to reduce fear and distress during port access and venipuncture.

Holistic Comfort Interventions for Pediatric Nursing Procedures: A Systematic Review

Comfort interventions for children during invasive nursing procedures have been well documented in the literature. It is important, however, to distinguish between the provision of holistic comfort management and pain alleviation. Holistic comfort focuses on treating the child’s whole procedural experience and includes more than simply reducing pain. In this literature review, 33 intervention studies were examined. These studies focused on evaluating comfort effects from nursing interventions on pain, anxiety, fear, and distress. Four themes of procedural comfort intervention emerged: music therapy, amusement and entertainment, caregiver facilitation, and a multifaceted approach. Important findings of this review, gaps in the literature, and implications for future research are discussed.

Procedural Preparation and Support as a Standard of Care in Pediatric Oncology

Youth with cancer undergo many repeated and invasive medical procedures that are often painful and highly distressing. A systematic review of published research since 1995 identified 65 papers (11 review articles and 54 empirical studies) that investigated preparatory information and psychological interventions for a variety of medical procedures in pediatric cancer. Distraction, combined cognitive-behavioral strategies, and hypnosis were identified as effective for reducing child pain and increasing child coping. Low- to high-quality evidence informed strong recommendations for all youth with cancer to receive developmentally appropriate preparatory information and psychological intervention for invasive medical procedures.

Comparison of Two Brief Parent-Training Interventions for Child Distress During Parent-Administered Needle Procedures

This randomized clinical trial employed a 2-group (general child behavior management training vs. distraction for pain management training) design across repeated parent-administered needle procedures. Forty-seven children with a chronic illness requiring recurrent injections were observed at baseline and 2 intervention sessions. Videotaped observations of parent-child interactions were coded for child behavioral distress and parents' use of behavior management strategies. Across groups, many children displayed minimal to no distress at baseline. Among participants with significant distress, neither intervention group displayed consistently decreased procedural distress or increased use of child behavior management strategies.

Behavioral approaches to anxiety and pain management for pediatric venous access

Pediatric venous access causes unnecessary anxiety and pain in children and, in turn, can have detrimental consequences. Behavioral approaches to pediatric venous access distress management can be organized temporally. Specifically, preparation before the procedure includes providing children with sensory and procedural information in an age-appropriate manner and providing training in coping skills. It is important to consider the timing, format, and content of the approach to provide optimal preparation for the unique circumstances of the individual patient. In addition to the child patient, preparing parents and teaching them which specific behaviors might be most helpful to their child should prove valuable to both patient and parents. During the procedure, there are benefits to providing secure and comfortable positioning. In addition, researchers recommend that adults encourage children to cope and actively engage children in distracting activities. For infants, there is support for the distress-mitigation properties of swaddling, skin-to-skin contact, breastfeeding, and sucrose. After venous access, distraction and encouragement of coping should speed recovery. In sum, research in behavioral approaches to pediatric pain management has provided recommendations for minimizing children's anxiety and pain associated with venous access.

Effects of videogame distraction using a virtual reality type head-mounted display helmet on cold pressor pain in children

OBJECTIVE

To test whether a head-mounted display helmet enhances the effectiveness of videogame distraction for children experiencing cold pressor pain.

METHOD

Forty-one children, aged 6-14 years, underwent one or two baseline cold pressor trials followed by two distraction trials in which they played the same videogame with and without the helmet in counterbalanced order. Pain threshold (elapsed time until the child reported pain) and pain tolerance (total time the child kept the hand submerged in the cold water) were measured for each cold pressor trial.

RESULTS

Both distraction conditions resulted in improved pain tolerance relative to baseline. Older children appeared to experience additional benefits from using the helmet, whereas younger children benefited equally from both conditions. The findings suggest that virtual reality technology can enhance the effects of distraction for some children. Research is needed to identify the characteristics of children for whom this technology is best suited.

Pain reduction during pediatric immunizations: evidence-based review and recommendations

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children <18 months of age and in the deltoid (upper arm) for those >36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

A comparison of distraction strategies for venipuncture distress in children

OBJECTIVE

To compare the effects of two pediatric venipuncture distress-management distraction strategies that differed in the degree to which they required children's interaction.

METHODS

Eighty-eight 1- to 7-year-old children receiving venipuncture were randomly assigned to one of three treatment conditions: interactive toy distraction, passive movie distraction, or standard care. Distress was examined via parent, nurse, self-report (children over 4 years), and observational coding. Engagement in distraction was assessed via observational coding.

RESULTS

Children in the passive condition were more distracted and less distressed than children in the interactive condition. Although children in the interactive condition were more distracted than standard care children, there were no differences in distress between these groups.

CONCLUSIONS

Despite literature that suggests that interactive distraction should lower distress more than passive distraction, results indicate that a passive strategy might be most effective for children's venipuncture. It is possible that children's distress interfered with their ability to interact with the distractor.

When Distraction Fails: Parental Anxiety and Children’s Responses to Distraction during Cancer Procedures

OBJECTIVE

To examine parental anxiety in the context of successful and unsuccessful distraction treatment of preschool aged children undergoing chemotherapy procedures.

METHODS

Twenty-nine children (M age = 42 months) experiencing intramuscular or portacatheter injections participated in the study. Parents and children were shown how to use a portable electronic toy as a distractor during chemotherapy injections. Parental anxiety was assessed at baseline and child distress was coded during each procedure.

RESULTS

Parents' baseline state anxiety accounted for 17% of the variance in changes in children's distress following distraction intervention. Parents of children who did not benefit from distraction reported significantly higher state anxiety at baseline than parents of the other participants.

CONCLUSIONS

Results highlight the importance of examining individual outcomes in intervention studies and suggest that parents' emotional states may moderate distraction treatment outcome in young children. Future research formally testing parent anxiety as a moderator is recommended.

Improving children's cooperation with tracheotomy care by performing and caring for a tracheotomy in the child's doll-a case analysis

Described is a 2-year-old child who required a tracheotomy for an obstructing laryngeal tumor. Post-operatively the child responded with extreme anxiety and refused to cooperate with tracheostomy care including suctioning, tie changing and cannula change. A novel approach was attempted. We performed a tracheotomy on the child's favorite doll and taught her to perform all the necessary tracheostomy care on the doll. Once the child became accustomed to treating the doll, it became much easier to care for her tracheostomy and compliance to treatment improved greatly to the point were restraint was no longer required. This model of mock surgery and care of a child's doll may be helpful in treating young children with tracheotomies.

Pain practices: a cross-Canada survey of pediatric oncology centers

Before implementing a pain education program, the Canadian Association of Nurses in Oncology conducted a national survey on cancer pain management. The survey focused primarily on adult cancer pain and a second survey was undertaken to describe the supports in place across Canada for best practice pediatric cancer pain management. Twenty-eight pediatric cancer centers responded to a survey that was composed of 48 questions about the types of supports that are in place related to pain assessment, management, and pain-related staff and family education. Results of the survey indicated that, for the most part, children have access to the components of best practice pain management. In addition, areas of strength and areas that need to be further developed were identified and the implications for the findings discussed.

Distraction for children of different ages who undergo repeated needle sticks

A distraction intervention for pain management and behavioral distress was implemented for six children with chronic illnesses and their parents as the children underwent repeated needle sticks. The children ranged in age from two to eight years. Several different cognitive distractors were used for the children based on their respective developmental levels. The needle stick procedures during which treatment was implemented included intramuscular injections, implanted port accesses, and intravenous placements. Nine sessions of distraction were provided in which a therapist taught parents to coach their children to use distraction techniques. Dependent measures included the child's behavioral distress and heart rate, parent ratings of the child's fear before the procedure, parent self-ratings of feeling upset during the procedure, and nurse ratings of the child's cooperation. Reductions in child behavioral distress during the distraction treatment program were observed in five out of the six cases. Concomitant improvements in parental reports of child distress, nurse estimates of child cooperation, and parents' self-report of feeling upset during the medical procedures also were found. Follow-up data were available for one of the successfully treated children. His improvements were maintained for both intramuscular injections and portacatheter accesses over 16 weeks without therapist involvement.