DESCRIPTION OF THE STRATEGY

Although pain management has been an area of interest for psychologists for some time, it
was only recently that pain in children and adolescents was recognized as a legitimate medical
and psychological concern. Before then, pain in children was seen as a fleeting, behaviorally
reflexive event that was not fully apprehended by children due to their developmental stage
and lack of cognitive understanding. It is ironic, then, that behavioral and cognitivebehavioral interventions have proven so effective in pain management in children.

Assessment
Effective pain management begins with an accurate assessment of pain. This can be
problematic, as many pain episodes are infrequent or occur only under specific circumstances.
However, the clinician should consider at least five areas for assessment of painlocation,
frequency, intensity, duration, and qualityand painfree periods. Pain location can be
assessed by asking where on the child's body the pain occurs. The child should be asked to
point to the pain, and the accompanying adult should be asked to verify this location. Pain
frequency should be assessed on both the micro and macro level: Is the pain constant or
transient? How often has it occurred during the past hour, day, and week? and When does it
occur more often? Pain intensity is usually gauged with a visual analog scale for younger
children or a verbal analog scale for older children. The Whaley-Wong visual analog scale can
range from 0 to 4 and have frowning and smiling faces as anchors. For older children, the
analog scale usually ranges from 0 (no pain) to 10 (worst pain ever). Pain duration is assessed
by inquiring how long pain occurs, once it begins, and what is associated with pain
remittance. Pain quality is subjective, but certain descriptive terms are commonly employed,
such as burning, stabbing, or squeezing. Children should be asked to describe the pain
themselves first, and then prompted with these terms if necessary. Finally, how often and
under what environmental and behavioral circumstances painfree periods occur should be
assessed.
It is important to obtain multiple assessments in multiple settings in order to increase the
likelihood of detecting patterns of pain as well as to assess for interand intrasubject variability.
For instance, it is helpful to know if the child reports more pain than usual for his or her
developmental age, if this pain is reported more at home than at school, and if this pain is
reported more in the presence of Mom as opposed to Dad. Moreover, a good assessment will
elucidate what type of pain the child is experiencing and will enable the clinician to target
pain behaviors and symptoms effectively. It is apparent that multiple variables affect what
type of intervention is chosen for pain; these multiple variables are not necessarily mutually
exclusive, often operating in conjunction with each other. Therefore, an accurate assessment
will consider these variables as overlapping and covariate.
For example, time of pain should be assessed. The clinician must know whether the pain is
acute or chronic. While both acute and chronic pain can be treated with standard behavioral
interventions such as distraction, as pain moves more into the chronic phase, more cognitive
coping skills can be utilized. For example, a child with sickle-cell disease may experience
pain crises only one or two times per year, but a child with chronic back pain resulting from
an automobile accident may experience daily pain. An assessment of frequency and duration
of pain will provide this information.

Another variable to consider during assessment is the origin of the reported pain. Pain
resulting from disease (whether that disease is chronic or acute) should be differentiated from
procedural pain. For example, a child with juvenile rheumatoid arthritis (JRA) will have a
different pain experience than a child who has to get an antibiotic shot at the pediatrician's
office. Obviously, frequency and duration of pain will co-vary with this variable. However,
not all chronic pain is disease related. For example, a child with diabetes may experience
frequent acute pain resulting from finger sticks.
Developmental aspects should also be taken into consideration. Older children report pain
differently than younger children. Hence, different types of interventions can be utilized in
varying degrees of intensity in order to achieve efficacy. In general, the clinician should
follow guidelines similar to those put forward in the child clinical literature, that is, behavioral
techniques for younger children, moving to more cognitive-behavioral with older adolescents.
In other words, as a child gets older, behavioral techniques are still recommended, but
cognitive coping skills begin to play a role in pain management.
Finally, the modality of the pain management intervention needs to be considered. Pain
interventions can take place with the child or adolescent, with the parent/family/medical staff,
or with both. Interventions aimed at a child's management of pain will necessarily be different
from interventions designed to utilize the child's family to help with pain management, but
these interventions should work in harmony toward the goal of pain management. In short,
pain is not unidimensional, and therefore the conceptualization and management of pain is not
unidimensional. Assessment techniques that focus on these variables will provide the clinician
with appropriate targets for intervention.

Interventions
In general, clinicians should attempt to accomplish several basic steps in pain management.
An accurate assessment of pain behaviors should reveal specific behaviors to target during
intervention. The contingencies that hold these behaviors in place should be modified so that
more adaptive behaviors will increase. These adaptive behaviors should be reinforced, and the
targeted pain behaviors should be punished or ignored. And all this should be accomplished
both with the child and any adults that significantly affect the child's environment, such as
parents or nurses. In the following section, these specific steps will be discussed in greater
detail.
Behavioral and cognitive-behavioral interventions have been shown to be the most effective
in helping children and adolescents manage pain. These techniques are the same as are used in
the treatment of other psychological disorders and need only mild accommodation to be
effective in this specific population. Specifically, distraction is the standard first-line
intervention for pain in children and adolescence. Children should be distracted by asking
them to describe objects in their immediate surroundings (i.e., What is that on TV? or Help
me count how many pictures there are in this room) or by asking them to describe events
from another time (i.e., Tell me what you had for breakfast this morning or Tell me about
your vacation). Imagery is also recommended, though its use with younger children may be
more difficult. Children can be trained to visualize a calm, soothing mental scene (such as the
beach or their bedroom) and then prompted to see this image during their painful episode.
Finally, progressive muscle relaxation (PMR) can be used to train children to tense and relax
large muscle groups. As children attain these skills, they can then be prompted to relax during

pain episodes. As children get older, they can be taught coping skills (such as positive selfstatements) in addition to behavioral techniques.
As with most techniques used in child psychology, adults need to be included in the
intervention for best results. This means teaching adults (parents, caregivers, nurses, etc.)
techniques that can then be used with the child or adolescent. Adults should be advised to
follow several guidelines: (a) reduce attention to pain behavior, within reason: after the initial
assessment regarding pain intensity, frequency, duration, location, and so on these questions
should not be asked again; also, responses to pain behavior should be reduced, and the child
should be assisted in coping with pain, other than an initial prompt to practice selfskills; (b)
normality should be encouraged: daily routines should be reinstated and maintained (school,
chores, activities), and appropriate coping skills should be modeled by the adult with the
child.

RESEARCH BASIS
The research shows that behavioral techniques (i.e., distraction and/or imagery) work better
than cognitive techniques alone (i.e., positive self-statements). These findings offer key
guidelines for the clinician's decision making regarding interventions. While most parents and
other adults may feel that distraction is too cold for a child who is experiencing pain, and
naturally feel inclined to engage in more emotionfocused, cognitive interventions, the
research clearly demonstrates that distraction works best for reducing pain behaviors. Many
adults naturally think that calming, soothing statements to a child in pain constitutes effective
caregiving. However, these behaviors typically serve as positive reinforcement for the pain in
children and can thereby extenuate and exacerbate the pain behaviors rather than reducing
them. Distraction, as a primary intervention for pain management in children and adolescents,
has been shown to be more efficacious at reducing pain intensity, frequency, and duration.
Research has also demonstrated that teaching children self-management techniques without
using an adult to model and prompt these behaviors is not effective. These primarily cognitive
techniques may have more efficacy with older children and adolescents as the target
intervention group. However, younger children need an adult to prompt them to engage in
these interventions. Hence, the clinician is encouraged to utilized caregivers or medical staff
to help implement pain management techniques with younger children. As the child gets
older, the clinician can move toward more self-directed interventions for the patient.

RELEVANT TARGET POPULATIONS AND

COMPLICATIONS
Since pain is a complex phenomenon, it can be difficult to assess and intervene upon, as has
been discussed above. However, any attempt at pain management would be misguided and
ultimately dangerous without consultation with a health care professional. Pain itself is
adaptive, and often the child or adolescent can be experiencing pain that is symptomatic of a
serious medical and physical concern. Attempts to minimize response to this sort of pain can
prove harmful. For example, a 4-year-old girl standing on a stool recently fell and struck the
back of her head on the edge of the kitchen counter. She cried only momentarily and then
began playing with her sisters again. Over the course of the evening, she intermittently
complained of head pain before returning to normal activity. Her father used distraction
techniques successfully; however, when he was checking on her as she slept that night, he
discovered that her pillowcase and the back of her head were bloody. She had a 2-inch
laceration with a large extradural hematoma; her father realized he had not thought to check
the back of her head. Since she had returned to normal activity so soon after the fall, her
father assumed that her pain behaviors were exaggerated, when in fact they were adaptive.
This case illustrates that pain management interventions can be very successful but should
only be attempted when medically appropriate.

CASE ILLUSTRATION
Sally was a 6-year-old female who had been recently diagnosed with type 1 diabetes,
previously known as insulin-dependent diabetes mellitus (IDDM). She had a 4-year-old sister
and lived with both biological parents in a rural community. She was brought to the
emergency department, where she was diagnosed and placed inpatient for stabilization and
diabetes care education, following standard medical care. There was no history of chronic
disease in her family and so no precedent for coping with medical procedures other than
occasional doctor visits.
Sally was very resistant to the daily finger sticks and insulin injections that are required in the
treatment for type 1 diabetes. She complained that they hurt and stated repeatedly that she did
not want to get stuck. Sally's mother was the primary caregiver during her hospital stay. Her
mother reported that though she knew the finger sticks and insulin injections were part of
diabetes care, she still had difficulty dealing with Sally's obvious pain.
Though minor in terms of overall invasiveness, finger sticks are nevertheless painful, due to
the large number of nerve endings located on the human finger tip. Likewise, insulin
injections are delivered with a hypodermic needle; these shots must be rotated about the torso
and thighs so that the same delivery site is not used repeatedly. This can be problematic, as
some individuals like to find sweet spots where they can give themselves a shot with less
pain involved.
The initial assessment indicated that Sally was most distressed about the finger sticks. At first
when the nurse would enter the room, she would become tearful, say no, no repeatedly, and
look to her mother. She would allow the nurse to stick her finger, though. However, when the
switch was attempted to get her mother to administer the finger stick, Sally engaged in these
same resistant behaviors and began stalling and negotiating with her mother. Sally's mother
would attempt to calm Sally before attempting the stick. This became problematic both for
mother and for the medical staff, as it would often take the mother 30 to 60 minutes to obtain

a finger stick. Sally's mother expressed concern about her ability to obtain a stick at home.
Sally reported that the pain was intense but quickly subsided. Her main concern was the fact
that this pain was going to be routine, a part of her regular day, from now own.
Interventions were focused on both Sally and her mother. Sally was taught to look away from
her finger during the time of the stick and to try to whistle when she exhaled, utilizing
distraction and deep breathing. Sally's mother was taught not to make any statements to Sally
other than look away and whistle; she was specifically told not to make calming statements
to Sally, but to quickly and efficiently engage in the behavior (i.e., administer the finger stick).
When Sally was able to have her finger stuck within 1 minute of the initiation of the stick, she
was rewarded with 15 minutes extra in the playroom on her hospital floor. After 2 days, this
time interval was reduced to 30 seconds from initiation of the stick.
Sally responded well to her mother's cues to engage in distraction and deep breathing.
Likewise, her mother (after some initial hesitancy) was able to refrain from calming
statements and to administer the finger stick swiftly. Sally particularly enjoyed the reward of
going to the playroom, and her nonresistant behaviors appeared to be rewarded by this. By the
day of discharge, Sally offered minor resistance. She and her mother were able to generate a
list of rewards that could be implemented at home to replace the time in the hospital
playroom.
This case illustrates assessment and treatment of intense, brief, chronic, treatment-related pain
in a young child. As Sally gets older, our plan is to engage her in more cognitive skills,
demonstrating to her how she has learned over time to cope with a less than desirable medical
condition.
T. David Elkin
Further Reading

Entry Citation:
Elkin, T. David. "Pain Management." Encyclopedia of Behavior Modification and Cognitive
Behavior Therapy. 2007. SAGE Publications. 15 Apr. 2008. <http://sageereference.com/cbt/Article_n2085.html>.