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Effects of preparatory information and distraction on children's cold-pressor pain outcomes: A randomized controlled trial

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Abstract

This experimental study investigated whether preparatory sensory information was more effective in managing children's pain when coupled with a distraction technique. Seventy-eight children aged 7–12 years were randomly allocated to 1 of 4 experimental conditions. They were given either a detailed sensory description of an imminent painful event (cold-pressor arm immersion in 10 °C water) or control instructions lacking sensory information. During the cold-pressor task, half the sample received an imagery-based distraction intervention. Pain measures included immersion tolerance, self-reported pain intensity, and facial pain responses. Self-reported coping style was assessed using the Pain Coping Questionnaire [Reid, G. J., Gilbert, C. A., & McGrath, P. J. (1998). The pain coping questionnaire: Preliminary validation. Pain, 76, 83–96]. The effects of information provision interacted with distraction for pain intensity but not pain tolerance. Children given sensory preparation reported less intense pain when this was coupled with distraction than when it was not. Children with a distraction-based coping style showed greater tolerance when assigned to a condition congruent with their coping style. These findings suggest ways to better prepare children for painful medical procedures.

Introduction

Information provision has an important role in children's healthcare. Preparatory information has been shown to reduce perceived pain intensity (Spafford, von Baeyer, & Hicks, 2002), to reduce distress during procedures (Margolis et al., 1998), and to improve post-operative adjustment (Margolis et al., 1998).

Procedural information (a description of what will be done) can be more effective if coupled with sensory information (a sensory description of what the patient will experience) (Suls & Wan, 1989). Since procedural information is often explained in terms of what the health professional will do, children with limited experience of medical procedures may find it difficult to translate procedural information into a clear set of expectations about what they will experience (Jaaniste, Hayes, & von Baeyer, 2007). Sensory information may be important in helping children generate more accurate expectations of a forthcoming procedure, leading to better self-regulation of coping responses (Leventhal & Johnson, 1983) and reduced anticipatory anxiety, particularly anxiety related to the unknown (Claar, Walker, & Smith, 2002).

Children who have had a previous negative medical experience, however, may be sensitized by information about a forthcoming procedure (Melamed, Dearborn, & Hermecz, 1983). A sense of helplessness may also result when contemplating what may be perceived as an imminent and unavoidable aversive experience. In such cases distress and helplessness may be minimized if accurate information about an impending painful experience is coupled with advice on what the child can do to cope with the experience (Melamed & Ridley-Johnson, 1988). However, little is known about how preparatory information interacts with children's use of non-pharmacological coping strategies like distraction.

Distraction may be defined as the intentional deployment of attention away from pain or other distressing stimuli and towards more pleasant or emotionally neutral stimuli. According to “fixed capacity” models of attentional processing (e.g., Kahneman & Treisman, 1984), individuals have a limited pool of attentional resources, the allocation of which is under some degree of conscious control. Focussing attention on a distractor is thought to leave fewer attentional resources for focussing on the pain experience. Distraction-based strategies for children's medical procedures are empirically well-supported (Uman, Chambers, McGrath, & Kisely, 2006). Nevertheless, distraction alone is not effective for all children in all painful contexts (e.g., Piira, Hayes, Goodenough, & von Baeyer, 2006). Children faced with an unfamiliar painful event may be inclined to monitor the experience because they believe that this will prevent unpleasant surprises.

The central argument that motivated the current research was that it may be possible to achieve better pain outcomes by combining the provision of sensory preparation with a coping strategy like distraction. Salmon, McGuigan, and Pereira (2006) found that children who received detailed sensory and procedural information before a voiding cystourethrogram plus distraction during the procedure demonstrated fewer distress behaviors than children who received only limited procedural information. However, this was largely due to the effects of distraction. There were no differences between the effects of detailed and limited information provision when both of these were coupled with distraction. To our knowledge, no other studies have investigated whether combining sensory information prior to a painful experience with distraction during the experience produces a synergistic effect.

When faced with stressors like painful procedures, there are stable individual differences in children's tendency either to seek out more information about the situation or to avoid it using strategies like distraction (Hubert, Jay, Saltoun, & Hayes, 1988). According to the “congruence hypothesis”, interventions should be matched to children's preferred coping style (Auerbach, Kendall, Cuttler, & Levitt, 1976; Christiano & Russ, 1998). However, not all studies have found support for this view (e.g., Smith, Akerman, & Blotcky, 1989). A secondary goal of this study was to assess children's habitual pain-coping styles (information-seeking or distraction) and examine whether such individual differences moderate the effects of information provision and distraction interventions.

Using the cold-pressor task (CPT) as an experimental pain stimulus, the current study was designed as a controlled evaluation of the efficacy of a factorial combination of sensory preparatory information (present or absent) and an imagery-based distraction intervention (present or absent). There were 4 main hypotheses. First, it was hypothesized that children receiving preparatory sensory information would have greater pain tolerance, lower pain-intensity ratings, and lower facial pain responses than children who did not receive this intervention. Second, children prompted to use distraction were expected to have better pain outcomes than those who did not receive this intervention. The most critical novel prediction was that children receiving preparatory sensory information as well as prompts to use distraction would have better pain outcomes than those receiving only one intervention. Finally, consistent with the congruence hypothesis, interventions congruent with children's preferred coping style were expected to produce greater pain tolerance and lower pain-intensity ratings. Although older children were expected to cope better with painful experiences, there were no a priori hypotheses regarding interactions between age and intervention type.

Section snippets

Participants

At least 72 participants were required, 14 in each of the 4 intervention groups, to provide sufficient power (α=.05, 2-tailed) to detect large group differences if these existed. A total of 79 participants, aged 7–12 years, were recruited from 3 Sydney primary schools (38 boys, 41 girls). Participants had no prior experience with the CPT. The parents of an additional 22 children declined permission for their children to participate. One child (male, 11 years) assigned to the sensory information

Participant characteristics

Fig. 1 is a flow diagram depicting sample size at various stages of the study. There were no significant differences between the experimental conditions in mean age, coping style, or anticipated pain. There were fewer females in the control condition (30%) than in the other conditions (information: 58%, distraction: 52%, information+distraction: 68%), but neither pain tolerance nor average pain-intensity ratings were significantly affected by gender (all F's<1.5).

Effects of sensory information and distraction on pain tolerance and intensity

To test the first 3 hypotheses,

Discussion

This study is among the first to examine the interaction between sensory information provision and use of a distraction technique on children's reactions to a painful experience. Given the multi-dimensional nature of the pain experience, we examined the effects of the variables of interest on 3 pain outcomes, namely pain tolerance, pain-intensity ratings, and facial pain responses.

There was partial support for the first hypothesis, with children provided with sensory information showing a trend

Conclusions

Children who received preparatory sensory information were likely to have better pain outcomes if they were also instructed in the use of a distraction strategy. Children who received prompts to engage in distraction, without receiving preparatory sensory information, had poorer pain outcomes. Children may be more able to engage in a distraction intervention if they know what to expect. The current study also provided support for the view that interventions should be matched to individual

Acknowledgments

The authors are grateful to the teachers and participating students at St Joseph's Primary School in Oatley, St Therese's Primary School in Mascot, and St Joseph's Primary School in Rockdale, New South Wales, Australia. The assistance of Amy Boland and Basia Radlinska with video taping, and Faye Sullivan and Nira Goren with facial coding was appreciated.

A research grant from the Sydney Children's Hospital Foundation is gratefully acknowledged. The first author is also grateful for fellowship

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  • Cited by (0)

    1

    Tiina Jaaniste was formerly Tiina Piira.

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