Distraction Techniques for Children Undergoing Procedurs

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nervous system is vulnerable to noxious stimuli duringdevelopment. Not only does pain have a negative impact on

creams can take up to 1 hour to provide sufficient epidermaland dermal anesthesia (Blount et al., 2006).

Journal of Pediatric Nursing (2012) 27, 652681 Corresponding author: Donna Koller, PhD.neurological development, but children whose pain has notbeen adequately treated in infancy or early childhoodreported lower pain thresholds as adolescents and adults(Ruda, Ling, Hohmann, Peng, & Tachibana, 2000). Pain isalso associated with heightened levels of distress and anxietyduring procedures, which can result in negative long-termemotional outcomes (Blount, Piira, Cohen, & Cheng, 2006;

Pediatricians and emergency physicians are often hesitantto administer analgesics in the ED (Mahan & Strelecky,1991; Selbst & Clark, 1990). For instance, MacLean,Obispo, and Young (2007) found that few to no pediatricpatients who presented at an urban ED received pharmaco-logic pain management for procedures such as venipunc-tures, IV catheter placement, and finger pokes (p. 87).Even when anesthetics are administered, pediatric patientscontinue to report procedural-related distress and pain(Dahlquist, Pendley, Landthrip, Jones, & Steuber, 2002).children, children, and adolescents has revealed that the Becker, Lovgren, Bates, & Minugh, 2006). However, these0hFogg, 1998; Lambert, 1eeves, 2006). Althougnpleasant, it has an adaptat tissue damage is abrotective response (Franaklander, & Dworkin,xposure to pain can haveThe study of pain anPAIN IS A complex, multidimensional and subjectiveexperience that consists of physiological, sensory, emotional,cognitive, and behavioral components (Broome, Rehwaldt,& 999; Sinha, Christopher, Fenn, &R h the experience of pain isu ive function; its presence signalsth out to occur, and it initiates ap ck & Stevens, 2000; Nagasako,O 2003). However, the prolongede deleterious effects.

d anxiety in infants, preschool

Brewer, Syblik, Tietjens, & Vacik, 2006; Howard, 2003;Ruda et al., 2000).

In particular, pediatric patients in the emergency depart-ment (ED) are often subjected to unexpected procedures thatcause pain and increased anxiety and distress (Blount et al.,2006). Intravenous (IV) insertions, intramuscular or subcu-taneous injections, central venous port access, and urethral orangiocatheter insertions are routine ED procedures. The useof topical creams, such as lidocaine and prilocaine (EMLA),to provide topical anesthesia has been shown to reduce thepain associated with these procedures (Skarbek-Borowska,A Critical Review of PediatricDonna Koller PhDa,, Ran D. Goldman MDaRyerson University, Toronto, Ontario, CanadabBC Children's Hospital, Vancouver, British Columbia, Can

Key words:Pediatrics;Distraction;Pain;Nonpharmacologic painmanagement;

Child life;Medical procedures

Pediatric patients are often spharmacologic interventions cachildren's attention away fromtechnologies associated with diarticle was to provide a criticpractice and future research.temperament as a means of optin health care decision making 2012 Elsevier Inc. All rightsE-mail address: [email protected] (D. Koller).

882-5963/$ see front matter 2012 Elsevier Inc. All rights reserved.ttp://dx.doi.org/10.1016/j.pedn.2011.08.001ren Undergoing Procedures:esearch

ted to procedures that can cause pain and anxiety. Althoughused, distraction is a simple and effective technique that directsxious stimuli. However, there is a multitude of techniques andtion. Given the range of distraction techniques, the purpose of thisessment of the evidence-based literature that can inform clinicalmmendations include greater attention to child preferences andng outcomes and heightening awareness around child participation

rved.Although limited pharmacologic interventions reduce the

likelihood of toxicity and can increase the speed at which

understanding of exemplary practices concerning nonphar-macologic pain management can assist health care pro-

under the direction of a librarian with a master's in

653Distraction Techniques for Children Undergoing Proceduresfessionals in offering coping strategies to pediatric patientsand their families. Given the range of distraction techniqueswithin pediatrics, the purpose of this article is to providea critical assessment of the evidence-based literature thatcan inform clinical practice and future research. Becausedevelopmental considerations are important in this literature,mesh terms from PubMed are applied here. Hence, the use ofthe term infant will coincide with age 02 years; preschoolchildren, 25 years; children, 612 years; and adolescents,1319 years. The studies reviewed here include participantsfrom 1 to 19 years of age.

Research Methods

An exhaustive search of the literature was conducted on(a) PsycINFO, which indexes the literature from psychologyand related disciplines such as medicine, psychiatry, nursing,sociology, and education; (b) MEDLINE, which focuses onbiomedical literature; and (c) CINAHL, the CumulativeIndex to Nursing and Allied Health Literature, which coversliterature relating to nursing and allied health professions. Avariety of keywords such as pediatrics, paediatrics, child(children), adol (adolescents), pain, anxiety, fear, distrac-tion, relaxation, virtual reality, guided imagery, television,coping, strategies, and music were used to conduct thesearch. Keyword combinations included coping and strate-gies, pediatrics and pain, distraction and coping, anxiety,coping, and pediatrics. A variety of these keywordcombinations were searched on two occasions within eachof the databases over an 18-month period. In both cases,searches were conducted at a major pediatric teaching facilityhealth care professionals can perform procedures, pediatricpatients are often left in pain, feeling anxious and distressed.

Distraction is a commonly used nonpharmacologic painmanagement technique used by both health care pro-fessionals and parents to attenuate procedural pain anddistress. Distraction operates on the assumption that byshifting a child's focus to something engaging and attractive,his or her capacity to attend to painful stimuli is hindered,thereby reducing pain, distress, and anxiety (Kleiber &McCarthy, 2006; Lambert, 1999). In pediatrics, distraction isoften defined as a strategywhether cognitive or behavioralthat draws a child's attention away from noxious painstimuli (Sander, Eshelman, Steele, & Guzzetta, 2002).Kleiber and Harper (1999) draw further distinctions anddefine distraction as a cognitive coping strategy thatpassively redirects the subject's attention or actively involvesthe subject with a task.

Despite its widespread use, there is no universallyaccepted theory to explain the function of distraction(DeMore & Cohen, 2005, p. 282). However, a greaterinformation science. The librarian had an understanding ofthe types of materials and subjects covered in the databasesand an awareness of the advantages/disadvantages ofcontrolled vocabulary searches and possible spelling differ-ences in terminology (e.g., British vs. American). All searchresults were limited to original pediatric studies publishedbetween 1990 and December 2009. The final search wascompleted in December 2009.

Searches revealed approximately 150 citations, whichincluded original articles from empirical research, reviewarticles, and non-empirical-based literature (e.g., anecdotalreports). The results were sorted to exclude duplicates (e.g.,multiple publications of same study) and nonempiricalresearch. Review articles were perused for additionalcitations from their reference lists, and an additional 3articles were ordered through interlibrary loan, as they werenot readily available. In total, 46 original study articles frompeer-reviewed journals were retrieved.

Selection criteria were determined by the scoring of twoindependent raters using the Quality of Study Rating Form(Gibbs, 1989). Articles were assessed and evaluated on anumber of issues, including identification of theoreticalframework, statement of purpose and research questions,recruitment procedures, sample sizes, methods, effect sizes,and validity of standardized measures. Each area received acorresponding score of either 0 (omission of area) or thenumber allotted to the category. Articles that received arating of at least 60 of 100 points were selected for inclusionin this review. For those articles that scored between 55 and65 points, a third rater confirmed inclusion or exclusion.Forty-six research articles met the selection criteria.

For each study, the content and rating were recorded usinga Microsoft Excel (2003) spreadsheet. Studies for this reviewpredominantly used quantitative methods through experi-mental designs (randomized controlled, quasi-experimental,and multiple case study), whereas only two studies usedmixed methods, which included interviews and narrativeaccounts. Methods of data collection included self-ratingscales, observer ratings, and parent reports. In particular,several measures of pain and distress were administeredthrough pain assessment scales, physiological indices, andbehavioral distress assessments. Review articles addressedspecific forms of distraction in the context of particularprocedures. Accordingly, the studies selected here investi-gated the effectiveness of various distraction modalities onpediatric patients' pain and anxiety. Modalities includeauditory, visual, bimodal, and interactive techniques.

Because of the number of techniques cited in theliterature, evidence is examined and organized under maincategories of active and passive forms of distraction.Active forms of distraction include interactive toys orelectronic games, virtual reality (VR), controlled breath-ing, and guided imagery/relaxation. In the case of activedistraction, participants are typically coached by an adultto engage in the activity. Passive forms of distraction

Table 1 Active Distraction

Study no. Reference Study Focus Sample Method Findings

1. Interactive toys (electronic and VGs)1 Data from

Dahlquist,Busby, et al.(2002)

Effect of three different V-techelectronic toys (V-techIndustries, Wheeling, IL) onpain management andbehavioral distress in childrenundergoing repeated needlesticks

6 preschool children andchildren (age range = 28 years old) with chronicillness and their parents

4 male and 2 female

Experimental design 9 distraction sessions wereprovided in which parentswere coached to usedistraction techniques

Participants behavioral distressmeasured by the ObservationScale of Behavioral Distress,observer ratings of participantdistress measured via theVAS, and parent self-reportswere collected

During the distractiontreatment program, 5 of 6participants had a clinicallysignificant reduction inbehavioral distress

Clinically significantimprovements in parentalreports of participant distress,nurse estimates ofparticipants' cooperation, andparents' self-report of feelingupset during the needle sticksprocedure

2 Data fromDahlquist,Pendley, et al.(2002)

Effect of an electronic toy as adistraction strategy to reduceanxiety in children undergoingintramuscular injections andsubcutaneous port access

29 preschool children (agerange = 25 years) fromthe outpatient hematologyoncology clinic

22 male and 7 female

2-Group repeated-measuresdesign

Random assignment todistraction condition (TexasInstruments [Dallas, TX]Touch and Discoverelectronic toy) or wait-listcontrol condition

Observer ratings collectedwith the Observation Scale ofBehavioral Distress

Participants receiving thedistraction intervention wererated as significantly lessanxious by nurses andparents, paired sample t test,t(28) = 4.96, p b .01;t(28) = 2.52, p = .02

Interactive games areeffective in decreasinganxiety and distress ofchildren, aged 25 years,undergoing invasive medicalprocedures

3 Data fromDahlquist et al.(2009)

Effect of an HMD helmet in VGdistraction for childrenexperiencing cold processorpain

41 children and adolescents(age range = 614 years)


Experimental stratifiedrandom sampling design

All participants underwent 1or 2 baseline cold processortrials followed by 2distraction trials (played thesame VG with and withoutthe helmet incounterbalanced order)

Pain threshold and paintolerance were measured foreach cold processor trial

When older children, aged1014 years, wore theHMD helmet, theydemonstrated significantlyhigher pain tolerance(ANOVA, M = 70.08,SD = 71.22) than youngerparticipants, aged 69 years(M = 31.74, SD = 40.36;t = 2.193, p b .05)

Both distraction conditionsresulted in improved paintolerance when comparedwith participants using nogames

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4 Data from Patelet al. (2006)

Effect of a handheld interactiveVG on reducing preoperativedistress

112 preschool children andchildren (age range = 412years) undergoing outpatientsurgery


Randomized, prospective study Random assignment to 1 of3 groups;1 - PP2 - PP + oral midazolam3 - PP + a handheld VG

Observer ratings onparticipants' anxiety collectedvia the Modified YalePreoperative Anxiety Scale andthe PosthospitalizationBehavior Questionnaire

The group that received aninteractive handheld VG andhad PP prior to surgeryexperienced a statisticallysignificant 63% decrease inanxiety. In contrast, there wasa 28% decrease for the groupprovided only with PP and26% for the group which hadboth PP + oral midazolam(chi-square test, 2 = 9.26,df = 2, p = .01)

Patients who were activelyengaged in playing with a VGhad statistically less distressat induction of anesthesiacompared with children whoonly had PP (KruskalWallistest, p = .04)

Statistically significantincrease in anxiety in groupsoral midazolam and PP atinduction of anesthesiacompared with baseline(Wilcoxon signed rank test,p b .01), but not in thehandheld VG group

A handheld VG is useful inreducing preoperative distress

2. VR5 Data from

Gershon et al.(2004)

Effect of VR as a distraction todecrease anxiety and painassociated with an invasivemedical procedure in cancerpatients

59 children and adolescentswith cancer (age range =719 years) undergoing IVport access


Pilot study: randomizedcontrol trial design

Random assignment to one ofthree groups:1 - VR distraction2 - a non-VR (interactive

game) distraction3 - Treatment with no

distraction Participants' self-reports werecollected, physiologicalresponses (pulse rate) weremeasured, and parentand nurse observer ratings

During VR, participants hadsignificantly lower pulserates, indicating a decrease inpain and distress duringinvasive medical procedures(p b .05). Analysis ofvariance tests were used toexamine treatment efficacybetween the 3 conditions withpost hoc analysis based onomnibus results

No statistically significantdifference in anxiety betweennon-VR and no-distraction

(continued on next page)

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Table 1 (continued)


recorded throughout theprocedure. Scales includedthe VAS and the Children'sHospital of EasternOntario Scale

conditions VR acts as a useful distracterduring invasive medicalprocedures

6 Data from Goldet al. (2006)

Effect of VR as a paindistraction for pediatric IVplacement

20 children (age range = 812years) requiring IV placementfor a MRI/CT scan


Experimental stratifiedrandom sampling design

Random assignment to 1 of 2conditions: VR distractionusing Street Luge, by FifthDimension Technologies(Irvine, CA), presented via ahead-mounted display, or acontrol condition with nodistraction

Self-report questionnairescompleted by participants, theirparents, and nurses via theVASs, Wong-Baker FACESPain Rating Scale, theChildhood Anxiety SensitiveIndex, the Child SimulatorSickness Questionnaire, andthe Child presencequestionnaire. Demographicinformation and satisfactionscores were also collected

Participants receiving VRdistraction were significantlymore satisfied with their painmanagement thanparticipants in the controlcondition, Pearson's r,F(1, 18) = 12.17, p b .01)

VR pain distraction waspositively endorsed by allparticipants as an effectivestrategy for decreasing painand distress during acutemedical interventions

7 Data fromNilsson et al.(2009)

Effects of using nonimmersiveVR during a needle-relatedprocedure on reported pain ordistress of children andadolescents in an oncology unit

42 preschool children,children, and adolescents(age range = 518 years)at the Queen SilviaChildren's hospital


Mixed-method design 21 participants assigned toan intervention group(nonimmersive VR); another21 patients to a control group

Before, during, and after theprocedures, participantsreported on pain and distressusing the CAS and the FAS.Heart rate was measured, andobservational pain scores wereobtained via the FLACC scale

Semistructured qualitativeinterviews were conducted atthe end

The self-reported painintensity and distress scalesdemonstrated no significantdifference between thegroups prior to, during, orafter the intervention

Participants undergoing aminor procedure foundnonimmersive VR to be anenjoyable experience; yettheir reported pain intensitydid not decrease

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8 Data fromSander et al.(2002)

Effect of VR glasses as adistraction measure to reducepain in adolescents undergoinglumbar punctures (LPs)

30 children and adolescents(age range = 1019 years)with cancer undergoing LPs


Experimental randomizedcontrol group design

17 participants randomlyassigned to the VR group(wore VR glasses andwatched a video) and 13adolescents in the controlgroup (no VR glasses)

All participants rated theirpain after LP using a VASand were interviewed toevaluate their experience

VAS pain scores tended to belower in the VR group ascompared with the controlgroup, indicating less pain

77% of participants in the VRgroup said the VR glasseshelped to distract them duringthe LP

VR glasses are effective inreducing the pain associatedwith LPs

9 Data fromSchneider andWorkman(2000)

Effect of using VR as adistraction intervention forchildren receiving outpatientchemotherapy

11 children and adolescents(age rage = 1017 years)undergoing treatment for amalignant disease

6 male and 5 female

Pilot study Participants were asked to usethe VR equipment duringtheir chemotherapy treatment

After treatment, participantscompleted the evaluation ofVR intervention form

9 of 11 participants indicatedthat the chemotherapytreatment with VR was betterthan previous chemotherapytreatments

All participants wanted to useVR again

VR is an effective distractionstrategy in enhancing positiveclinical outcomes

10 Data fromSharar et al.(2007)

Effectiveness of VR as adistraction technique in childrenundergoing postburn physicaltherapy

88 children, adolescents,adults, and seniors (agerange = 665 years) affectedby burn injuries

75% of participants wereaged 618 years


Prospective, randomized,controlled, within-subjectdesign

Participants received bothconditions: standardanalgesic (opioid and/orbenzodiazepine) care andstandard analgesic care +immersive VR distraction

Participants self-reportmeasures of subjectivepain were collected via the100-mm GRS

Compared with the standardcare condition, patients underVR distraction reportedstatistically significant lowerpain ratings for intense pain,pain unpleasantness, and timespent thinking about pain(SASd, GRS, 54.2 3.1 vs.43.5 3.5, p = .003; GRS,41.0 3.6 vs. 30.3 3.0,p = .01; GRS, 47.1 3.5 vs.29.5 3.0, p b .001).Age did not affect outcome ofpain measures

VR distraction provides asignificant amount of painrelief to patients undergoingpostburn physical therapy

11 Data fromWolitzky et al.(2005)

Effect of VR as a distractionstrategy to decrease distressduring port access procedure

20 children and adolescents(age range = 714 years)


Experimental randomizedcontrol trial design

Random assignment to eitheran immersive VR

Participants in the VRcondition experiencedsignificantly less pain,MANOVA, t(18) = 4.13,


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Table 1 (continued)


environment during theprocedure or a non-VRcontrol condition

Participants' distress wasassessed through a self-ratings scale (the VAS),objective physiological data,and behavioral measures(Children's Hospital ofEastern Ontario Pain Scale)

p b .01, and had significantlylower pulse rates during theprocedure, MANOVA,t(18) = 2.14, p b .05, than thecontrol group

VR was effective in reducingparticipant distress andanxiety on all measures

3. Controlled breathing12 Data from

French et al.(1994)

Effect of an active distractiontechnique, blowing out airrepeatedly, on reducing painduring immunization

149 preschool childrenand children (age range =47 years) having preschooldiphtheria, pertussis, andtetanus immunization

71 male and 79 female (thisdoes not add up to 149, butthese are the numbers used inthe article)

Randomized, unblinded,controlled study design

Participants were divided into4 groups. Two groups werecreated for the experimentalgroup;1a - Taught to blow out

when they received ashot in addition tobeing taught the VAS

2a - Taught to blow out butnot taught VAS. Thecontrol group also hadtwo groups

1b -Taught to blowout duringa shot; however, theywere taught the VAS

2b - Not taught eithertechnique.

Participant self-reports andparent and nurse ratings onparticipants' pain (VAS) werecollected. Observer ratings onparticipants' pain (OSBD) werealso collected

Participants who were underthe experimental conditions,i.e., taught to blow out airduring the procedure, hadsignificantly fewer painbehaviors (MannWhitneyU test, n = 70 vs. n = 77,p b .04), and reportedsignificantly less pain(MannWhitney U test,n = 36 vs. n = 39, p = .06)than the control conditions

Simple distraction techniques,like blowing out airrepeatedly, can be effective inhelping preschool childrenand children between the agesof 4 and 7 years cope withimmunization

13 Data from Lalet al. (2001)

Comparison of eutecticmixture, a type of localanesthetic (EMLA) cream,versus placebo in childrenreceiving distraction therapy forvenipuncture

27 preschool childrenand children (age range =48 years) attending forvenipuncture

Gender of participants notspecified

Prospective, randomized,double-blind, placebo-controlled, clinical trial design

All participants were givendistraction therapy by aplay specialist prior to

No statistically significantdifference in pain scoresbetween the treatment andcontrol groups were found

Low pain scores wereobtained in both groups,

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and during the venipuncture 17 participants wereassigned to the treatmentgroup (EMLA) and 10participants assigned tothe control condition(placebo cream)

Objective pain scores werecollected at the end of theprocedure

indicating the effectiveness ofdistraction therapy

14 Data fromManne et al.(1990)

The use of party blowerscombined with parentalcoaching and positive stickerreinforcements to help reducepain and stress duringvenipuncture for invasivecancer treatment

23 preschool children andchildren (age range = 39years) requiring physicalrestraint to completevenipuncture


Experimental alternateassignment design

13 participants in thebehavioral intervention group(instruction in attentiondistraction, use of partyblowers, paced breathing, andpositive reinforcement) and10 participants in theattention control group(parents encouraged to usetheir own ideas to divertchild's attention duringtreatment)

Participant distress (observed,self-reported, parent rated,and nurse rated), parentdistress, and nurse distresscollected via the ProcedureBehavior Rating Scale, theWong-Baker FACES PainRating Scale, and the VAS

Significant reduction inparticipants' distress, parentalratings of their child's pain,and parental anxiety occurredin the behavioral interventiongroup over the course of 3intervention trials.Correlations among the 4measures of participantdistress were all significant,with coefficients rangingfrom .39 (Pearson's r,p b .001; parents rateddistress and child self-report)to .80 (Pearson's r, p b .01;observed distress and nurse-rated distress)

Participants' perception ofpain was not significantlyaffected by the behavioralintervention

The significant reduction inparticipant's distress, parentalratings of their child'sdistress, and parental anxietydemonstrates theeffectiveness of distractioninterventions and parentalinvolvement for patientsundergoing repeated invasivecancer treatments

15 Data fromPeretz andGluck (1999)

Effect of an active distractiontechnique, repeated breathingand blowing out of air, on the

50 preschool childrenand children (age range =37 years)


Half the participants were

More participants in theintervention group than in thecontrol group significantly


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Table 1 (continued)


pain behavior and facial displayof children receiving localanesthesia injections prior todental treatment


assigned to the interventiongroup (asked to breathedeeply before and duringadministration of theinjection and to blow air out)or the control group (norepeated breathing and airblowing)

Measures not specified

expressed their wish to havethe same technique usedduring the second visit(p = .033)

Participants in theintervention groupdemonstrated less hand andtorso movements and lesseyebrow bulging andexpressed less pain than thecontrol group

4. Guided imagery and relaxation16 Data from Ball

et al. (2003)Effect of guided imagery andrelaxation for the treatment ofRAP in children

10 preschool children,children, and adolescents(age range = 518 years)with RAP

Gender of participantsnot specified

Pilot study: randomizedcontrol trial design

Random assignment to eitheran intervention group or await-list control group

Participants receivedrelaxation training andguided imagery during 4weekly 50-minute sessions

Pain diaries and the Wong-Baker FACES Pain RatingScale were completed byparticipants and their parentsat 0, 1, and 2 months

Participants experienced astatistically significant 67%decrease in pain during thefirst 2 months of therapy(chi-square for trend,p b .00l)

The use of relaxation alongwith guided imagery is aneffective and safe treatmentfor childhood RAP

17 Data fromBroome et al.(1994)

Effect of distraction andimagery with children duringpainful procedures

14 preschool children,children and adolescents(age range = 315 years) withacute lymphocytic leukemiaand receiving LPs


Multiple case study design Baseline data obtained at thefirst 3 visits prior to theintroduction of relaxation,imagery, and distractionexercises

Self-ratings of participant'sfear and pain and parentanxiety were collected,videotaped observations ofthe participants' and parents'behavior were taken, andchild pain ratings wereobtained at all 3 visits. Scalesused included the ChildMedical Fear Scale, the

Participant's behavioralresponses to the procedurevaried considerably, but theirfear scores were stable andtheir reports of painsignificantly decreased overtime (t = 3.21, p = .008)

Guided imagery can be usedas a means of reducingpediatric patients' pain andanxiety and parental anxietyand distress

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Observation of BehavioralDistress Scale, the Baker-Wong FACES Scale, theSpielberger State/TraitAnxiety Scale, and the ParentBehavior Tool

18 Data from Huthet al. (2004)

Effect of imagery, in addition toroutine analgesics, in reducingtonsillectomy and/oradenoidectomy pain andanxiety after AS and at home

73 children (age range =712 years) scheduled fortonsillectomy oradenoidectomy


Unblinded experimentalstudy

36 participants assigned tothe treatment group: watcheda videotape on the use ofimagery and listened to a30-minute audiotape ofimagery 1 week prior tosurgery; they listened to onlythe audiotape 14 hours aftersurgery and 2227 hoursafter discharge from AS

37 participants assigned to theattention control group: theyreceived standard care

Participant self-reportmeasures on pain and distresswere collected via the OucherScale and the FAS. Diaryentries were also collectedand analyzed

Those who had imageryreported significantly lesspain shortly after AS than thecontrol group (MANCOVAat T2, F[3.66] = 3.02, p = .04)

Health care providers can useimagery to reducepostoperative pain followingtonsillectomy and/oradenoidectomy

19 Data from Huthet al. (2009)

Effectiveness of a guidedimagery audio CD in reducingpostoperative pain, increasingrelaxation, and stimulatingimagery in children

17 children (age range =712 years) hospitalized overa 7-month period for a varietyof surgeries 8 male and 9 female

Cross-sectional pre/posttestdesign

Compared pain and relaxationscores before and afterlistening to the CD titledMagic Island: Relaxationfor Kids

Demographic informationand participant self-reports,via the Oucher Scale, werecollected. Interviews wereconducted with participants

Listening to the CDstimulated imagination of 14(82%) of the 17 participants

Participants reported asignificantly lower pain scorepre- to postintervention.Mean pain score before theCD was 4.31 (SE = 0.61),whereas it was 2.75 after theCD (SE = 0.49, paired t test,t[15] = 3.49, p = .0033).However, although painratings decreased, nostatistically significantincrease in relaxation wasfound

Guided imagery proved


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Table 1 (continued)


effective in reducing painwhen the child was in ahighly anxious state, butresults were not alwayssustained after the participantreturned home (effect wasshort-lived)

Relaxation may not be anecessary component for painreduction, but stimulatingimaginations might bebeneficial

20 Data fromLambert (1996)

Effect of hypnosis/guidedimagery on the postoperativecourse of pediatric surgicalpatients

52 children and adolescents(age range = 719 years)scheduled for elective surgery


Experimental 2-group,pre/posttest design

Random assignment to 1 of2 groups; the experimentalgroup was taught guidedimagery by the investigator,and the control group spenttime with a research assistant

Participant self-reportmeasures on pain and distresswere collected via theNumeric Pain Scale and theSpielberger State AnxietyInventory

Significantly lowerpostoperative pain ratings forparticipants in the guidedimagery group (paired t test,mean 3.9, p b .01)

State anxiety was reduced forthe experimental group andincreased postoperatively forthe control group

Positive effects found withhypnosis/guided imagery forthe pediatric surgical patient

21 Data fromPederson(1995)

Effect of guided imagery onchildren's pain and anxietyduring cardiac catheterization

24 children and adolescents(age range = 917 years)scheduled for cardiaccatheterization



Random assignment to 1 of3 groups:1 - Control group2 - Presence group3 - Imagery group

Physiological, psychological,and behavioral data wereused to rate pain and anxietyduring cardiac catheterization

Participants in the imagerycondition displayed fewerdistress behaviors duringcardiac catheterization

Participants in the presencecondition reported the lowestlevels of pain

22 Data fromSmart (1997)

Effect of music and guidedimagery in relaxing childrenand reducing the use ofsedatives before MRI

20 preschool children andchildren (age range = 48 years) scheduled for anMRI


2-Group experimental design Random assignment to eitherthe treatment group (listenedto the Magic Island tape usingheadphones) or the control

7 of 10 participants wholistened to the music andimagery tape remained stillfor the MRI and did notrequire sedation.

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group (listened to no musicusing headphones)

Participants who were unableto remain still during thetesting were given sedationaccording to hospital protocol

Pretest questionnaire and miniinterviews were conductedwith participants

Only 2 of the 10 participantswho did not hear the taperemained calm and did notneed sedation

23 Data fromWeydert et al.(2006)

Effect of guided imagery as atreatment for RAP in children

22 preschool children,children, and adolescents(age range = 518 years)


Experimental randomizedcontrol trial design Participants wererandomized to learn eitherbreathing exercises alone orguided imagery withprogressive muscle relaxation

Using a daily diary,participants reported thenumbers of days with pain,pain intensity, and missedactivities due to abdominalpain

Depression, anxiety, andsomatization measured inboth participants and parentsat baseline using a variety ofrating scales (BowelSymptom Questionnaire,Child Depression Inventory,Multidimensional AnxietyScale for Children, EASTemperament Scale, ChildSomatization Scale,Symptoms Checklist-90, andthe Parent BondingInstrument)

Guided imagery resulted instatistically significantdecreases in the number ofmissed activities due to painand the number of days inpain within the first month(67% vs. 21%, p = .05; 85%vs. 15%, p b .01) and secondmonth (82% vs. 45%,p b .01; 95% vs. 77%,p = .05). All analyses werecompared using the Student'st test or chi-squarestatistical test

Guided imagery can helpimprove social functioningand effects can be sustainedover the long term

Note: HMD = head-mounted display; VG = video game; PP = parental presence; CT = computed tomography scan; VAS = visual analog scale; MANOVA = multivariate analysis of variance; RAP = recurrentabdominal pain; AS = ambulatory surgery.

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Table 2 Passive Distraction


1. Auditory distraction: music1 Data from Aitken

et al. (2002)Effect of audio distractionin reducing pain, anxiety,and disruptive behaviorduring pediatric dentalprocedures

45 preschool children andchildren (age range =46 years)


Experimental design Participants were assigned to 1of 3 groups:1 - Upbeat music2 - Relaxing music3 - No music

Parent-reported anxiety measures viathe Modified Corah Anxiety Scale;self-reported anxiety measured viathe Venham picture scale; heart rate;behavior measured via the BehaviorRating Scale; and pain measuredusing the VAS

No statistically significantdifferences were found among the3 groups across any variables

Audio distraction was not aneffective means of reducinganxiety, pain, or uncooperativebehavior during pediatricrestorative dental procedures

2 Data from Artset al. (1994)

Effect of a local anestheticcream (EMLA) and musicdistraction in reducing orpreventing pain fromneedle puncture (IVcannulation) in children

180 preschool children,children, and adolescents(age range = 416 years)undergoing surgery undergeneral anesthesia via IVcannulation


Double-blind experimentalstratified random sampling design

The 3 age groups were 46 years,711 years, and 1216 years;60 children were assigned toeach group

3 groups were assigned:1 - Received lidocaine-prilocaine

emulsion (EMLA, AstraZeneca, Wilmington, DE).

2 - Received a placebo cream thatwas indistinguishable inappearance from EMLA

3 - Received music(contemporary, upbeat music)via earphones.

Participant self-reports werecollected via the FPS andVAT, and globalobservation ratings were collected

Participants in the EMLAcondition reported significantlyless pain on all 3 pain scales thanthose in the placebo or distractionconditions (FPS, 2 = 2.62 vs.2.58 vs. 1.42, p = .001; VAT,2 = 4.55 vs. 4.33 vs. 2.18,p b .001; GBAS, 2 = 1.23 vs.1.10 vs. 0.58, p = .003)

Participants, 46 years old,regardless of intervention, reportedsignificantly more pain than childrenand adolescents more than 6 yearsold on all 3 pain measures (FPS, 2 =2.85, p b .001; VAT, 2 = 5.11, p b.001; GBAS, 2 = 1.17, p = .002)

Gender, experience withvenipuncture, and level of child'sanxiety had no bearing on the results

3 Data fromBaghdadi (2000)

Effect of music and whitenoise in the management ofsensitive children treatedusing EDA for restorative care

16 children (age range =912 years) with lowpain tolerance duringoperative proceduresunder electronicanesthesia alone


Experimental design Sound (music and random noise)was used in combination with EDA

Pain was assessed using the ColorScale and the Sound, Eye, andMotor Scale

Behavior was assessed by theNorth Carolina Behavior

The use of EDA combined withaudio diversion resulted insignificant improvements inbehavior and comfort during dentalprocedures (t test)

The music promoted relaxation,whereas noise in combination withelectronic signals suppressed pain

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Rating Scale Audio analgesia and EDA may beused successfully in combination toreduce pain and enhance relaxation

4 Data from Bo andCallaghan (2000)

Effect of NNS, MT, andcombined NNS and MTversus no intervention onheart rate, transcutaneousoxygen levels, and painbehavior on neonates inintensive care units havingblood taken by a heel-stickprocedure

27 infants (age range =3041 weeks) in thespecial care baby unit of agovernment-fundedgeneral hospital inHong Kong


Within-subjects, counterbalancing,repeated-measures design

All patients received NNS, MT,combined NNS and MT, and nointervention in a random order eachtime after a heel-stick procedure

Observer ratings were collected toassess infant's pain via the NeonatalInfant Pain Scale and the VAS.Heart rate and transcutaneousoxygen levels were also collected

All 3 interventions significantlyreduced infants' heart rate (Wilks' = 0.647; F[2, 27] = 18.93; 2 =0.35; p b .0001), improved theirtranscutaneous oxygen levels(Wilks' = 0.481; F[2, 27] =37.42; 2 = 0.51; p b .0001), andreduced their pain behaviors(Wilks' = 0.312; F[2, 27] =76.42; 2 = 0.68; p = .0001)

Health professionals using NNS +MT when doing heel sticks canimprove the transcutaneous oxygenlevels of infants and reduce theirpain and pain behaviors

Using MT alone can help decreasethe heart rate of infants during heel-stick procedures

5 Data from Gousie(2001)

Effect of MT in reducingpediatric pain perceptionduring injections

35 preschool children andchildren (age range =210 years) from the RapClinic at the UniversityHospital of Cleveland

19 female and 16 male

Experimental randomized controltrial design

19 participants in experimentalgroup (MT)

16 participants in control group(no MT)

Observational behavioralassessments collected via theBehavioral Assessment DialysisRating Form

Experimental group demonstrated adecrease in pain perception and lessbehavioral distress during theinjections

Music is correlated with improvedinteractions between preschoolchildren and children, parents,and health care professionals inaddition to facilitating greater painmanagement and quicker recoverytimes

6 Data from Jeffs(2007)

Effect of self-selecteddistraction on pain andanxiety during allergytesting in adolescents

32 children andadolescents (age range =1117 years) who werescheduled for food and/orenvironmental allergyskin testing


Randomized, unblind experimentaldesign

Random assignment to 1 of3 conditions:1 - Self-selected distraction

(music, teen books, movies,music videos, sportsprograms, cartoons)

2 - Investigator-selecteddistraction (watched nursingrecruitment video)

3 - Usual care

No statistically significantdifference was found in painratings among the 3 groups

Lower anxiety and greaterengagement with distraction wasassociated with less pain

Greater engagement withdistraction associated with lessanxiety


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Table 2 (continued)


Participants' pain was measured bythe adolescent pediatric pain tooland the Wong-Baker FACES painrating scale

7 Data from Joyceet al. (2001)

Effect of music and eutecticmixture of local anesthetics(EMLA) on pain responsesof neonates undergoingcircumcision

23 infants (age range =less than 24 hours)

All participants weremale

Randomized, double-blindexperimental design

Infants received EMLA or placebocream; applied at least 1 hour priorto procedure. The audio stimulus(music by Baby go to Sleep) playedjust prior to the procedure

Pain intensity was measured basedon observational responses usingthe Riley Infant Pain Scales. Heartrate, respiratory rate, oxygensaturation levels, salivary cortisollevels, and length of cry were alsocollected

Pain ratings were significantlylower for infants in the musiccondition by the end of procedure(F = 5.53, df = 1/21, p = .03)

Music is an effective distractionstrategy in reducing pain for infantsundergoing circumcision

8 Data from Malone(1996)

Effect of live music on thebehavioral distress andanxiety levels of pediatricpatients receiving needleinsertions

40 infants, preschoolchildren, and children(age range = 07 years)


Experimental design 20 patients in the experimentalcondition received live musicduring a variety of needleinsertions

20 patients in the control conditionreceived no music

Observer ratings of behavioraldistress collected via an adaptedversion of the PredominantBehaviors Category List andanother behavioral distress scale(name of scale not specified)

The experimental group exhibitedsignificantly less behavioraldistress than the control group(ANOVA, F = 9.6, p b .05)

Music can be an effectivedistraction technique in helpingchildren cope during painfulprocedures

9 Data from Megelet al. (1998)

Effect of audio-tapedlullabies on physiologicaland behavioral distress andperceived pain amongchildren during routineimmunization

99 healthy preschoolchildren and children(age range = 36 years)attending animmunization clinic



Random assignment to either anexperimental group receiving musicalintervention during procedure, orcontrol group with no music

Behavioral distress was measuredvia the OSBD. Pain perception wasmeasured via the Oucher Scale andphysiological variables (heart rate,blood pressure) were also collected

No statistically significantdifferences were found betweenexperimental and control groups onheart rate, blood pressure, or painperception scores

There was a significant differencein the OSBD scores between boysand girls. Boys showed significantlymore distress behaviors duringimmunization (KruskalWallis, z =1.97, p = .048)

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Audio-taped lullabies can helpreduce distress for childrenreceiving immunizations

10 Data from Tanabeet al. (2002)

Effect of nursinginterventions in decreasingpain for children with minormusculoskeletal trauma andmoderate pain

76 preschool children,children, and adolescents(age range = 517 years)who were accompaniedby a parent or legalguardian and had minorextremity trauma (distalto the elbow and knee) inthe ED


Experimental systematicassignment design

Participants were assigned to 1 of 3intervention groups and monitoredfor 60 minutes:1 - Standard care (ice, elevation,

immobilization)2 - Standard care and ibuprofen3 - Standard care and distraction

(music or toys) Interviews were conducted; childself-reports on pain were collectedvia the Wong-Baker FACES Scaleand the Numeric Rating Scale, andpatient satisfaction questionnairesadministered

A statistically significant decreasein pain for all patients occurred at30 minutes (ANOVA, F = 4.39,p b .05) and was maintained at60 minutes

The distraction group demonstrateda statistically significant reductionin pain compared with the othergroups at 30 minutes; this reductionwas maintained at 60 minutes(repeated-measures ANOVA,F = 47.07, p b .05)

Distraction techniques can beeffective in adjunct to analgesia forchildren with musculoskeletal pain

11 Data fromWhitehead-Pleauxet al. (2006)

Effect of MT on pain andanxiety in pediatric burnpatients during a dressingchange

14 children andadolescents (age range =616 years) from theShriners Burns Hospital-Boston

5 male and 9 female


Patients were randomly assigned to1 of 2 groups: experimental group(live music) or control group(verbal interaction)

Psychological and behavioral datawere assessed through the Wong-Baker FACES Pain Rating Scale,the Fear Thermometer, and theNursing Assessment Pain Index.Physiological data including heartrate, and respiration rates werealso collected

No statistically significantdifference between experimentaland control groups on perceivedpain and respiration rates

Participants in the MT groupdisplayed significantly greaterbehavioral distress (MannWhitney U, 9.69 vs. 4.58, p = .02)and reported higher anxiety levelsduring the treatment (MannWhitneyU, 9.79 vs.3.75, p = .002)than the control group, howeverhad significantly less variance inheart rate (MannWhitney U, 4.75vs.8.58, p = .003)

12 Data fromWhitehead-Pleauxet al. (2007)

Effect of MT on pain andanxiety in pediatric burnspatients during procedures

9 children andadolescents (age range =716 years) from ShrinersBurns Hospital-Boston

3 male and 6 female

Mixed-method design Each participant received MTduring nursing procedures

Interviews were conducted;participant self-reports of pain andanxiety were collected via theWong-Baker FACES Scale and theFear Thermometer; behavioraldistress was collected by nurses viathe Nursing Assessment of Pain

A statistically significant differencewas found between the level ofengagement and behavioral distressin the active and passive groupscompared with the nonengagedgroup (Tukey's test, p = .000)

Results showed different trends infindings based on age. Subjectswho were 15 years or olderexperienced the greatest benefits


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Table 2 (continued)


Index; and physiological measures(heart rate and blood oxygen level)were measured

from MT; children and adolescentsunder 15 years of age experiencedless benefit

2. Audiovisual distraction: television13 Data from Landolt

et al. (2002)Effect of cartoon movieviewing as a practical andlow-cost technique toreduce pain in burn patientsduring dressing changes



Single-subject experimental design Experimental condition: cartoonmovie plus a standardizedanalgesic medication

Control condition: standardizedanalgesic medication only

Observer ratings of behavioraldistress using the OSBD

No statistically significant effect wasfound during cartoon moviedistraction on observed behavioraldistress in patients

Cartoon movies may not be asufficiently effective in reducingpreschool children and children'sdistress during burn dressingchanges

14 Data from Salmonet al. (2006)

Effect of proceduralnarration and distraction onchildren's memory of anddistress during a VCUG(x-ray of the kidneys)

62 preschool children andchildren (age range =2.57.5 years)


Experimental design Assignment to 1 of 3 conditions:

1 - Complete proceduralinformation during theVCUG, with cartoon video(CI + D)

2 - Limited proceduralinformation, with a cartoonvideo (PI + D)

3 - Limited proceduralinformation (standard care, PI)

Observer ratings of distress werecollected via the Child-AdultMedical Procedure InteractionScale-Revised, and interviewswere conducted with participants1 week after the intervention

Compared with the PI condition(standard care), participants in theCI + D condition recalledsignificantly more information(t[52] = 2.07, p b .05), reportedthe VCUG as less painful, and weresignificantly less distressed

No statistically significantdifferences between thePI + D and PI conditions werefound

Procedural narration together withdistraction can enhance preschoolchildren's and children's memoryand reduce distress during aninvasive procedure

Note: EDA = electronic dental anesthesia; NNS = nonnutritive sucking; MT = music therapy; VCUG = voiding cystourethrogram.

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predominantly consist of listening to a story or music,

the participants' nurses and parents, paired sample t test,t(28) = 4.96, p b .01; t(28) = 2.52; p = .02. Notably,

decreasing anxiety prior to surgery. The group that

Schneider & Workman, 2000; Wolitzky, Fivush, Zimand,Hodges, & Rothbaum, 2005).

669Distraction Techniques for Children Undergoing Proceduresresults were maintained over the 8-week duration of thechemotherapy treatment.

A similar study was conducted by Patel et al. (2006),with 112 children between the ages of 4 and 12 years todetermine what types of distraction were most effective inviewing television, or watching movies. Finally, somestudies compared the effectiveness of active versuspassive forms of distraction. Tables 1, 2, and 3 providesummaries of the studies categorized under the variousforms of distraction.

Active Distraction

Active forms of distraction promote a child's involvementin an activity during a procedure. These methods requireparticipants' active engagement and therefore tend to involveseveral sensory components. Some of the most commonlyemployed forms of active distraction in clinical settingsconsist of interactive toys, VR, controlled breathing, guidedimagery, and relaxation.

Interactive Toys (Electronic and Video Games)

Interactive video and electronic games are multisensorytoys involving audiovisual, kinesthetic, and tactile senses,requiring a player's active cognitive, motor, and visual skills.To be played successfully, avid attention is necessary, and itis common for children to become so engrossed in thesegames that their surroundings become nonexistent (Dahl-quist, Pendley, et al., 2002). For this reason, electronic gamesare viewed as an active distraction technique with thepotential of blocking multiple senses for the reductionof pain and anxiety (Dahlquist, Pendley, et al., 2002; Patelet al., 2006).

Researchers in this area have evaluated the effect ofdistraction on patients undergoing preoperative care (Patelet al., 2006), cancer treatment (Dahlquist, Busby, et al.,2002; Dahlquist, Pendley, et al., 2002), and venipuncture(MacLaren & Cohen, 2005). Most researchers citeinteractive games as effective in reducing the anxiety andstress of pediatric patients undergoing invasive procedures.Dahlquist, Pendley, et al. (2002) evaluated the effects of aTouch and Discover electronic toy as a diversion method,with preschool children receiving repeated injections forchemotherapy. The toy is interactive and involves auditory,visual, motor, and tactile stimulation. Age-appropriateimages are depicted on a screen with child charactersinstructing participants how to play; the game requiresspecific photos to be touched to elicit correlated sounds.This study reported a statistically significant decrease inanxiety and distress with the use of the toy as reported byVR is supported as a feasible and useful tool ofdistraction for children and adolescents undergoing cancertreatment (Gershon, Zimand, Pickering, & Rothbaum,2004; Sander et al., 2002; Schneider & Workman, 2000;Wolitzky et al., 2005), burn treatment (Sharar et al., 2007),and IV placement (Gold et al., 2006). A reduction in thelevel of pain (Gershon et al., 2004; Sharar et al., 2007),anxiety (Gershon et al., 2004), time focused on pain(Sharar et al., 2007), and behavioral distress (Wolitzkyet al., 2005) is reported.

The nature of the VR software has been most effectivewhen tailored to a specific diagnosis or treatment. Forexample, some researchers have evaluated the effectivenessof VR as a distraction technique for burn victims bypresenting unique forms of software such as Hunter andPetterson's SnowWorlda (Sharar et al., 2007). This programis a three-dimensional virtual environment intended to createan illusion of freezing ice. The environment comprisesreceived an interactive handheld video game in additionto having their parents present prior to surgery experienceda statistically significant 63% decrease in anxiety. Incontrast, anxiety decreased by 28% for the group providedonly with parental presence and 26% for the group thathad both parental presence and oral midazolam (chi-squaretest, 2 = 9.26, df = 2, p = .01).

In summary, some studies report benefits associated withthe use of interactive toys and electronic games. Given therange of electronic toys and games available on the markettoday, additional research is necessary. For example, specifictypes of games and toys may be more effective andappropriate for pediatric patients. Indeed, child life special-ists working in pediatric settings do not recommend games ortoys that feature violence or horror-like images. Despitegenerally favorable reviews of this intervention, carefulchoices must be made regarding the types of games offeredto pediatric patients.

Virtual Reality

VR technology provides a computer-based, three-dimen-sional interactive environment with auditory, visual, andoften tactile components. VR is novel, multisensory, andbelieved to hold an advantage over other distractiontechniques by virtue of its cocoon-like equipment and itsengaging and immersive nature (Dahlquist et al., 2007). Setin an enclosed headset, VR provides the opportunity for amental escape by strategically drawing individuals into analternative world. By controlling their perceptual environ-ment, patients can redirect multiple senses from a hospitalenvironment to one involving positive and entertainingactivities (Gold, Kim, Kant, Joseph, & Rizzo, 2006;

Table 3 Active and Passive Distraction


1 Data from Bellieniet al. (2006)

Effect of active or passivedistraction duringvenipuncture in children

69 children (age range =712 years) undergoingvenipuncture

Gender of participants wasnot specified

Experimental random d controltrial design

Randomly divided int groups:1 - Control group, n istraction2 - Mothers perform active

distraction3 - TV group, cartoo were used

for passive distra on Participant and parent lf-reportmeasures collected to easuredistress (type of meas s notspecified)

Procedures performed during TVwatching (passive distraction) wereindicated as significantly lesspainful than control or proceduresperformed during active distraction(MannWhitney U, SD [24.5 vs.21.36 vs. 8.65, p b .05)

TV watching can be more effectivethan active distraction performedby parents

2 Data fromBerenson et al.(1998)

Effect of video eyeglassesfor reducing anxietyinduced by the pelvicexamination amongchildren of different races

89 preschool children andchildren (age range =38 years) scheduled toundergo a genitalexamination



Random assignment t of 3distraction groups dur genitalexamination:1 - Passive play (bei read to)2 - Active play (sing , blowing

bubbles)3 - Viewing a movie rough

video eyeglasses Levels of vocalized d ess anddistress expressed by ysicalbehavior and requests remotional support we observedand recorded

Participants reported ir level ofsatisfaction at the end theexamination

Findings demonstrated lowestlevels of physical distress amongchildren who used video glasses(univariate F test, F[2, 77] = 4.1,p b .02) and highest levels ofphysical distress among childrenwho were randomly assigned topassive play (post hoc, p b .05)

Participants using video glassesexpressed significantly higherlevels of satisfaction than thoserandomized to active play(KruskalWallis, p = .001)

Viewing a movie through eyeglasses can be effective in reducingdistress in children undergoinggenital examinations

3 Data fromDahlquist et al.(2007)

Effect of active versuspassive distraction using aVR type head-mounteddisplay helmet for childrenexperiencing cold processorpain




Random assignment t of 3conditions:1 - Active distraction play a

video game)2 - Passive distraction atch a

prerecorded footag f someoneelse playing a vid game)

3 - No-distraction co olcondition

Pain threshold and pa tolerance

Participants in both active andpassive distraction groups showeda statistically significantimprovement in pain tolerance/threshold when compared withbaseline in Trial 2 (post hocanalyses, M = 14.73, SD = 4.10vs. M = 28.86, SD = 5.55, p b.001; M = 19.70, SD = 3.95 vs.M = 27.08, SD = 5.34, p = .02)

Participants in the control conditionshowed no improvements in pain

670D.

Koller,R.D.

Goldmanize

o 3o ded

nsctisemure

ize

o 1ing

nging

th

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theof

ize

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(

(we oeontr

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measured tolerance or threshold The active condition for painthreshold was significantly moreeffective than the passive condition(t = 2.683, p b .01)

4 Data fromMacLaren andCohen (2005)

Comparison of 2 distractionmodalities, interactive toyand movie, against astandard care control groupfor venipuncture distress inchildren

88 infants, preschoolchildren, and children (agerange = 17 years) receivingvenipuncture at a universityhospital

52 male and 36 females

Experimental randomize controltrial design

Participants were group by age(13 and 47) and rand mlyassigned to 1 of 3 cond ons:1 - Standard care (con l)2 - Active toy distracti n (toy)3 - Passive distraction ovie)

Demographic data, obse ationalmeasures (Observation ale ofBehavioral Distress), pa icipantand parent self-reports ( ale notspecified), nurse self-rep rt (VAS),and observational codin werecollected

Participants in the passive group(movie) were significantly moredistracted and less anxious thanchildren in the active condition(ANOVA with follow-up t test,t[51] = 2.74, p b .01)

Children in the active group weremore distracted than children in thecontrol condition (ANOVA withfollow up t test, t[52] = 6.84,p b .01)

No statistically significantdifference in distress betweenactive condition and standard carecondition

A passive strategy may be moreeffective than an interactivedistraction during venipuncture

5 Data from Masonet al. (1999)

Effect of using distractionfor reducing children's painand distress duringprocedures


Range of cancer diagnoses 3 male and 4 female

Experimental repeated-measuresdesign

3 conditions:1 - Control2 - Brief film3 - Short story deliver during

repeated procedure in arandomized sequen e

Observers collected dist ss ratingsvia the OSBD. Overall havioraldistress was also obtain

Pairwise comparisons using theWilcoxon matched pairs signedranks test found the mean ranks forthe observer ratings of overallbehavioral distress for the shortstory intervention was significantlylower than both the control group,z(N = 7) = 2.23, p b .05, andcartoon film intervention,z(N = 7) = 2.05, p b .05.

Simple parentchild interactivedistraction tasks, such as engagingin a short story, could be used byparents to reduce child's distressduring procedures

6 Data fromPrabhakar et al.(2007)

Effect of audio andaudiovisual distraction inmanagement of anxiouspediatric dental patients

60 preschool children andchildren (age range =48 years) with no previousdental experience


Experimental design Assignment into 1 of 3 roups:

1 - Control2 - Listened to audio p sentation

through headphone duringtreatment

Statistically significant differencewasobserved between the control groupand audiovisual group (p b .05)

In the audiovisual group, a highlysignificant (p b .01) pulse rate wasobserved between the first and


671Distraction

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edoititroo(mrvScrtscog

edscrebeed

g

res

Table 3 (continued)


3 - Shown audiovisualpresentationthrough television duringtreatment

Observer ratings collected via theVenham's Picture Test andVenham's Rating of ClinicalAnxiety and physiologicalresponses (pulse rate and oxygensaturation) measured to determineparticipants anxiety

third visit, between the first andfourth visit, between the secondand third visit, and between thesecond and fourth visit.

Between the second and fourthvisit, the audiovisual distractiongroup demonstrated a statisticallysignificant difference in anxietylevels (p b .05)

Audiovisual distraction wasstatistically more effective inmanaging anxious pediatric dentalpatients

7 Data from Sparks(2001)

Effect of 2 forms ofdistraction, touch andbubble blowing, oninjection pain in preschoolchildren

105 preschool childrenand children (age range =46 years) needing DPTimmunizations


Quasi-experimental design Random assignment to 1 of3 treatments with their DPTinjection:1 - Touch2 - Bubble blowing3 - Standard care

Prior to injection, a measure of fearwas obtained using the ChildMedical Fear ScalePain was measured via the OucherScale

Both forms of distraction, touchand bubble blowing, hadstatistically significant effects onreducing injection pain perception(ANOVA, F = 6.48, p = .013)

8 Data fromStevenson et al.(2005)

Effect of CCLSintervention during routineperipheral venousangiocatheter insertion onchild procedure-relateddistress in ED




Random assignment to CCLSintervention or standard care

Following assessment of child,CCLS chose visual or auditorydistraction, breathing exercises,singing, or verbal interaction.

Participants' anxiety collected viathe OSBD-r, the State-TraitAnxiety Inventories, and customersatisfaction surveys

Group that received CCLSintervention showed a statisticallysignificant difference over standardcare on stress and behavioralmeasures in participants 47 yearsold. Mean difference of 3.28 OSBD-runits (95% confidence interval =0.146.41, p b .05). Statisticalanalysis included chi-square or Fisherexact test for categorical variables andindependent 2-tailed Student's t testfor continuous variables

No statistically significantdifferences in child or parentanxiety or customer satisfactionbetween groups

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9 Data fromWindich-Biermeir(2007)

Effect of self-selecteddistracters (bubbles, I Spy:Super Challenger book,music table, VR glasses,handheld video games, orbubbles) on pain, fear, anddistress in patients withcancer undergoing portaccess or venipuncture

50 preschool children,children, and adolescents(age range = 518 years)with cancer


Intervention-comparison groupdesign

Patients randomly assigned tocomparison group (standard care)or intervention group (distraction +standard care)

The intervention group received afull explanation of the procedure,parental presence during theprocedure, the use of a topicalanesthetic over needle puncturesite, and a self-selected distraction(books, music, handheld videogame, VR glasses or bubbles)

Participant self-reports rated painand fear, parents rated participants'fear, and nurses rated participants'fear and distress and conductedinterviews. Scales included CAS,Glasses Fear Scale, ObservationScale of Behavior Distress, and theinvestigator-developed IV PokeQuestionnaire

The intervention group showedsignificantly less fear and distressas rated by the nurse and parentsduring and after the procedure(MannWhitney U, 9.42 3.93,8.3 1.7, p = .03)

Self-selected distraction has thepotential to reduce fear and distressduring port access and venipuncture

Note: DPT = diphtheriatetanuspertussis; CCLS = certified child life specialist. GBAS = global assessment of behavioral reactions scale; VAT = visual analogue toy.

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scenery depicting cold rain, icy hills, and snow. Multisensory in cold water. After each trial, the pain threshold (elapsed

of variance [ANOVA],M = 70.08, SD = 71.22)then youngerparticipants (t = 2.193, p b .05) aged 69 years old. Results

674 D. Koller, R.D. Goldmaninteraction using computer keyboard, joystick, mouse,and/or head and eye movements is required by patients.Research examining the effects of Hunter and Petterson'sSnowWorlda for patients undergoing burn treatment sup-ports it as an effective means of distraction (Sharar et al.,2007). Patients' self-reported subjective pain ratings basedon a 0100 graphic rating scale (GRS) comprised the mainoutcome measure. This allowed the investigators to assesspatient ratings for intense pain, pain unpleasantness, and timespent thinking about pain (Sharar et al., 2007). The studyfound that all participants, regardless of age, had a significantmean reduction (20%) in worst pain intensity from standardcare (SASd, GRS, 54.2 3.1 vs. 43.5 3.5, p = .003), 26%decrease in pain unpleasantness (SASd, GRS, 41.0 3.6vs. 30.3 3.0, p = .01), and 37% decrease in the timespent thinking about pain (SASd, GRS, 47.1 3.5 to 29.5 3.0, p = .001).

Although outside the temporal boundaries of this review,Schmitt et al. (2010) recently conducted a randomizedcontrolled, within-subjects study with 54 patients (619years old) examining the effects of Hunter and Petterson'sSnowWorlda. The findings demonstrate a significantdecrease in pain ratings (p b .05) and improved affect(fun) during VR (p b .001). The analgesia and affectimprovements were maintained over multiple therapysessions, suggesting that VR is an effective nonpharmaco-logic adjunctive pain reduction technique for the pediatricburn population.

In addition to tailoring images to suit the diagnosis ortreatment, VR can be administered wearing a helmet(immersive) or not wearing a helmet (nonimmersive). In arecent study, investigators examined the effects of usingnonimmersive VR during a needle-related procedure onreported pain or distress of patients aged 518 years in apediatric oncology unit (Nilsson, Finnstrom, Kokinsky &Enskar, 2009). Nilsson et al. (2009) assigned 21 participantsto an intervention group (nonimmersive VR) and another 21participants to a control group. Both groups underwent eithervenous punctures or subcutaneous venous port devices.Before, during, and after the procedure, the patient rated hisor her pain intensity and distress by using the ColorAnalogue Scale (CAS) and Facial Affective Scale (FAS).The Face, Legs, Activity, Cry, and Consolability (FLACC)scale was developed to measure observational pain inchildren. Heart rate was recorded by a pulse oximeter 5minutes before and during the procedure. Semistructuredinterviews were conducted at the end and later analyzedusing qualitative content analysis. Participants found non-immersive VR to be an enjoyable experience, and yet, theirreported pain intensity did not decrease (Nilsson et al., 2009).

In another study, Dahlquist et al. (2009) comparednonimmersive and immersive forms of VR. Forty-oneparticipants, aged 614 years, were involved in twodistraction trials in which they played the same videogamewith or without the helmet. Their task was to place their handfrom this study showed that both distraction conditionsresulted in improved pain tolerance when compared withthose using no videogames (Dahlquist et al., 2009). Finally,Gershon et al. (2004) conducted a study with children andadolescents with cancer from 7 to 19 years of age.Participants who required port access were randomlyassigned to a VR distraction intervention, a non-VRdistraction, or treatment as usual without distraction.Throughout the procedures, pain and distress evaluationswere collected, pulse rates were monitored, and behavioraldistress was observed. ANOVA tests were used with posthoc analysis to examine the treatments in the threeconditions. They found a decrease in the staff ratings ofparticipants' pain and distress as indicated by significantlylower pulse rates during VR (p b .05) compared with theother two conditions. No significant differences were foundfor the non-VR condition versus the no-distraction conditionon pulse rate.

In summary, VR is a complex and costly method thatholds promise as an effective intervention. Several authorshave called for larger sample sizes and more heterogeneousparticipants to determine how VR can be used mosteffectively (Dahlquist et al., 2009; Gershon et al., 2004;Gold et al., 2006; Lange, Williams, & Fulton, 2006; Shararet al., 2007; Wolitzky et al., 2005). It appears that wearinga helmet versus not wearing a helmet may be moreeffective for patients between the ages of 10 and 14 years,as noted by Dahlquist et al. (2009), whereas Nilsson et al.(2009) added that comparisons between nonimmersive VR(no helmet) and games showed no differences in reportedpain intensity. However, Dahlquist et al. (2009) used aproxy stimulus for pain. Clinicians may need to determinewhether immersive or nonimmersive forms of VR areappropriate for particular patients, taking into considerationthe age and temperament of the patient. Finally, someauthors call for more research to test the efficacy andfeasibility of VR across a range of noninvasive and invasiveor potentially more distressing procedures (Gershon et al.,2004; Lange et al., 2006).

Controlled Breathing

Controlled breathing can be characterized as a cognitivebehavioral distraction technique in which patients deliber-ately pace their breathing. It is considered an active form ofdiversion that induces relaxation (Lal, McClelland, Phillips,time until the participant reported pain) and pain tolerance(total time they kept the hand submerged in the cold water)were measured (Dahlquist et al., 2009). Another groupreceived no VR. Children and adolescents between the agesof 10 and 14 years who wore a helmet demonstratedstatistically significant increases in pain tolerance (analysis

Taub, & Beattie 2001; Peretz & Gluck, 1999; Sparks, 2001).

divert their child's attention during treatment. Althoughthere was a significant reduction in preschool children's

Guided imagery and relaxation have been evaluated as a

675Distraction Techniques for Children Undergoing Proceduresand children's distress, parental rating of their child's pain,and parental anxiety (Pearson's r, p b .001), children'sperception of pain was not meaningfully affected by thebehavioral intervention (Manne et al., 1990). These authorssuggest that because measures of preschool children andchildren's self-reported pain did not produce statisticallysignificant results, party blowers may be less effective thanmore interactive activities for patients from 3 to 9 yearsold undergoing invasive cancer treatments. Further re-search is required to determine the use of controlledbreathing over time (i.e. multiple invasive procedures;Manne et al., 1990) and how it compares with other formsof active distraction.

Guided Imagery and Relaxation

Guided imagery is another cognitivebehavioral tech-nique intended to help pediatric patients reach a state ofrelaxation that can influence the body's pain perception(Huth, Van Kuiken, & Broome, 2006). It is simple,noninvasive, self-regulative, cost-effective, and appropriatefor preschool children, children, and adolescents who havecreative imaginations (Ball, Shapiro, Monheim, & Weydert,2003; Huth, Broome, & Good, 2004; Weydert et al., 2006).Distraction through guided imagery and relaxation hasbeen implemented in a variety of ways. Pediatric patientsare most often guided in muscle relaxation and thenencouraged to let their minds wander, imagine, and focuson a scene/ environment that is pleasurable, peaceful, orrelaxing. Other forms of guided imagery are facilitatedthrough audio prompts such as the envisioning of a story(Ball et al., 2003; Broome, Lillis, McGahee, & Bates, 1994;Lambert, 1999; Weydert et al., 2006).Controlled breathing has been studied using bubble blowing(Sparks, 2001), breathing exercises (French, Painter, &Coury, 1994; Peretz & Gluck, 1999), and party blowers(Manne et al., 1990).

Most research involving controlled breathing haveincluded children undergoing minor procedures such asimmunizations (e.g., routine shots; French et al., 1994;Sparks, 2001), anesthesia injections for dental surgery(Peretz & Gluck, 1999), and venipunctures (Lal et al.,2001; Manne et al., 1990). Some of these studies havereported a reduction in pain and expressed pain behaviorsfor children adhering to controlled breathing exercises(French et al., 1994; Peretz & Gluck, 1999). For example,Manne et al. (1990) tested the use of party blowerscombined with parental coaching and positive stickerreinforcements to help reduce pain and stress duringvenipuncture for invasive cancer treatment. The interven-tion group was compared with an attention control groupin which parents were encouraged to use their own ideas tomeans of reducing pain and anxiety in preschool children,children, and adolescents (Broome et al., 1994; Huth et al.,2004; Lambert, 1999; Pederson, 1995; Weydert et al., 2006),which can in turn affect parental anxiety and distress(Broome et al., 1994) and decrease missed activities due topain (Weydert et al., 2006). In general, research supportsguided imagery and relaxation as effective distractiontechniques for decreasing pain and anxiety in pediatricpatients (Ball et al., 2003; Huth et al., 2004; Lambert, 1996;Pederson, 1995).

In a recent study, investigators examined the effectivenessof a guided imagery program using a compact disc (CD)program by Mehling, Highstein, and Delamarter (1990),titled Magic Island: Relaxation for Kids. This CD wasdesigned by child life specialists to reduce postoperativepain, increase relaxation, and stimulate imagery in childrenand young adolescents (Huth, Daraiseh, Henson, &McLeod,2009; Smart, 1997). A sample of 17 children and adolescentsbetween the ages of 7 and 12 years were assessed before andafter listening to the CD, and pain and relaxation scores weregenerated to assess the CD's effectiveness in reducingpostoperative pain, increasing relaxation, and stimulatingimagery (Huth et al., 2009). Results of this study showed thatlistening to the CD stimulated the imagination of 14 (82%) ofthe 17 children (Huth et al., 2009). Participants also reportedsignificantly lower pain scores from pre- to postintervention,paired t test, t(15) = 3.49, p = .0033; however, no meaningfulincrease in relaxation was reported, thereby suggesting thatrelaxation may not be a necessary component for painreduction but rather that stimulating imaginations might bebeneficial (Huth et al., 2009).

In other studies, guided imagery resulted in statisticallysignificant decreases in the number of missed activities dueto pain and the number of days in pain, which can lead toimproved social functioning (Huth et al., 2004; Weydertet al., 2006). Weydert et al. (2006) conducted a study with22 children and adolescents aged 518 years. Theparticipants were separated into two groups; the firstgroup received guided imagery and progressive musclerelaxation, whereas the second group received onlyprogressive muscle relaxation. Group results were comparedusing the chi-square or Student's t test. Findings demon-strated that participants in the guided imagery groupcoupled with breathing exercises experienced a greaterstatistically significant decrease in the number of days withpain during the initial month (67% vs.21%, p = .05) and thefollowing month (82% vs.45%, p b .01). Accordingly, thisgroup also demonstrated a greater statistically significantdecrease of days with missed activities during the initialmonth (85% vs. 15%, p = .02) and the following month(95% vs. 77%, p = .05).

Huth et al. (2004) conducted a study with 73 childrenaged 712 years to investigate the effectiveness of imageryand routine analgesics in reducing anxiety and tonsillectomyand/or adenoidectomy pain after surgery in the hospital and

at home. This study found that there was a statistically

Music is a widely used form of auditory distraction

Auditory distraction techniques have been administered

676 D. Koller, R.D. Goldmanbecause it is noninvasive and inexpensive and requires noactive engagement (Aitken, Wilson, Coury, & Moursi, 2002;Tanabe, Ferket, Thomas, Paice, & Marcantonio, 2002).Edwards (1999) wrote a review of the literature addressingmusic therapy and found that singing familiar songs andlistening to music were generally effective techniques fordistracting pediatric patients from pain and distress duringprocedures. In addition, music is hypothesized to inducerelaxation and compete with pain stimuli to reduce anxietyand perceived pain (Baghdadi, 2000; Gousie, 2001; Joyce,Keck, & Gerkensmeyer, 2001; Malone, 1996; Whitehead-Pleaux, Baryza, & Sheridan, 2007).

Types of auditory distracters include live music (Gousie,2001; Malone, 1996; Whitehead-Pleaux, Baryza, & Sheri-dan, 2006) and recorded music and sounds (Baghdadi, 2000;Bo & Callaghan, 2000; MacLaren & Cohen, 2005; Megel,Houser, & Gleaves, 1998; Smart, 1997; Tanabe et al., 2002).The type of music examined in the literature varies; some useupbeat sounds (Aitken et al., 2002; Arts et al., 1994),whereas others use calm sounds (Aitken et al., 2002).significant decrease in pain postoperatively between the twogroups during their recovery in hospital, multivariateanalysis of covariance [MANCOVA] at T2, F(3.66) = 3.02,p = .04. Although these studies appear to have similarfindings, there were differing effects over time, with Weydertet al. (2006) finding that the impact of guided imagery wassustained over the long term, whereas Huth et al. (2004)found the effects short lived. For example, guided imageryproved effective in reducing pain when the participants werein a highly anxious state, but results were not alwayssustained after they returned home (Huth et al., 2004).

Taken together, active forms of distraction can producefavorable outcomes for preschool children, children, andadolescents experiencing various levels of pain. In somecases, the ability to participate in active forms of distractionmay require situations in which mild to moderate pain levelsare expected. It is also reasonable to assume that based ondevelopmental level, some preschool children may havedifficulty engaging in activities that demand considerablecognitive capacities (e.g., guided imagery, VR).

Passive Distraction

Passive forms of distraction require that the child remaincalm and quiet during a procedure. In this case, distraction isachieved through patients' observation of an activity orstimulus rather than their overt participation. Auditory andaudiovisual techniques are the most common forms ofpassive distraction used with pediatric patients.

Auditory Distraction: Musicto infants, preschool children, children, and adolescentsundergoing dental treatment (Aitken et al., 2002; Baghdadi,2000), venipuncture (Bo & Callaghan, 2000; Malone, 1996),IV cannulation (Arts et al., 1994), allergy testing (Jeffs,2007), circumcision (Joyce et al., 2001), musculoskeletalpain (Tanabe et al., 2002), injections (Gousie, 2001; Malone,1996), and burn treatment (Whitehead-Pleaux et al., 2006;Whitehead-Pleaux et al., 2007). Many of these researchersreport that age-appropriate music is effective at distractingpatients by increasing relaxation (Baghdadi, 2000), relaxingpatients by decreasing procedural pain (Gousie, 2001; Joyceet al., 2001; Tanabe et al., 2002; Whitehead-Pleaux et al.,2007), anxiety (Whitehead-Pleaux et al., 2007), and distress(Gousie, 2001; Malone, 1996; Megel et al., 1998; White-head-Pleaux et al., 2007).

In one mixed-method study, live music had a positiveeffect on burn patients aged 716 years (Whitehead-Pleauxet al., 2007). Participants believed that music inducedrelaxation and fostered greater coping while decreasing thetime required for the procedure. In another study, Gousie(2001) found that music was correlated with improvedinteractions among pediatric patients, parents, and healthcare professionals in addition to facilitating greater painmanagement and quicker recovery times. Music can beoffered in conjunction with other pain management tech-niques, such as medications or anesthesia (Joyce et al.,2001). For example, Tanabe et al. (2002) found that thecombination of music and administration of anestheticsproved most statistically significant in reducing pain(KruskalWallis, z = 1.97, p = .048).

In contrast, several studies refute the efficacy of music fordecreasing anxiety or pain in preschool children, children,and adolescents (Aitken et al., 2002; Arts et al., 1994; Megelet al., 1998; Whitehead-Pleaux et al., 2006). Disparatefindings may be due to the length and type of treatment, thepatient's age and exposure to the painful stimuli prior tointroducing music (Bo & Callaghan, 2000; Gousie, 2001;Malone, 1996; Whitehead-Pleaux et al., 2007), and the levelsof acute pain experienced during a procedure (Whitehead-Pleaux et al., 2007). Researchers call for more clearlydesigned, well-controlled studies on the use of music as acognitivebehavioral strategy for pain management (Joyceet al., 2001; Whitehead-Pleaux et al., 2006).

Audiovisual Distraction: Television

Televisions are particularly commonplace in pediatrichospitals. They are cost-effective, easily accessible (Cohen,Blount, & Panopoulos, 1997), and entertaining (Cassidyet al., 2002). Studies have included evaluations of childrenwatching television during venipunctures (Bellieni et al.,2006; MacLaren & Cohen, 2005), burn treatments(Kelley, Jarvie, Middlebrook, McNeer, & Drabman, 1984;Landolt, Marti, Widmer, & Meuli, 2002), cancer treatments(Mason, Johnson, & Woolley, 1999), genital examinations

(Berenson, Wiemann, & Rickert, 1998), voiding cystoure-

eyeglasses was effective for preschool children and childrenundergoing standard genital examinations. Watching a

however, that more invasive or painful procedures require

677Distraction Techniques for Children Undergoing Proceduresmovie was significantly more effective at reducing anxietyand distress than singing and blowing bubbles or being readto, as children viewing television with video eyeglasses hadthe lowest levels of distress, univariate F test, F(2, 77) = 4.1,p b .02).

In contrast, several studies show that television andmovies are insufficient at reducing pain or distress duringprocedures when compared with other methods (Cassidy etal., 2002; Landolt et al., 2002; Mason et al., 1999; Salmon etal., 2006). For example, Mason et al. (1999) found both shortstories and interactive toys as more effective than watchingtelevision during painful procedures, z(N = 7) = 2.05, p b.05. In a randomized control study comparing the effective-ness of watching television versus watching a blank screen,Cassidy et al. (2002) found that regardless of whether the TVwas on, a reduction in pain was experienced by children whoshifted their focus to the screen. They concluded thatdistraction in and of itself can have an analgesic effect.

Because the use of television or movies appears to offerlimited degrees of effectiveness, some researchers recom-mend more interactive audiovisual strategies (Cassidy et al.,2002). For example, Cohen et al. (1997) suggest that thecombination of different techniques, such as additionalcoaching by a nurse in conjunction with television, couldfoster better outcomes.

Comparing Active and Passive Formsof Distraction

Comparisons between active and passive forms ofdistraction have led to mixed and inconclusive findings(Bellieni et al., 2006; Berenson et al., 1998; MacLaren &Cohen, 2005; Mason et al., 1999; Sparks, 2001). Activestrategies are often hypothesized as superior to passivedistraction because they demand multisensory engagementthat intercepts multisensory pain stimuli (Dahlquist et al.,2007; Dahlquist, Pendley, et al., 2002; Mason et al., 1999;Peretz & Gluck, 1999; Windich-Biermeir, 2007). The notion,thrograms (Salmon, McGuigan, & Pereira, 2006), andimmunizations (Cassidy et al., 2002; Cohen et al., 1997).Some studies have found television to be successful indecreasing perceived pain (Bellieni et al., 2006; Berensonet al., 1998; Cohen et al., 1997) and alleviating distress(MacLaren & Cohen, 2005) during a variety of procedures.

In a randomized control study comparing parental supportversus television watching, television was more effective indistracting children from pain (Bellieni et al., 2006).Berenson et al. (1998) compared passive movie distractionthrough video eyeglasses with passive distraction (being readto) and a form of active distraction (singing and blowingbubbles). They report that viewing a movie throughengagement from a variety of senses is empiricallysupported. In one study comparing two distraction tech-niques (auditory versus audiovisual distraction for dentalpatients), researchers found that multisensory modalitiesserved to distract multisensory pain stimuli and thus weresignificantly effective in reducing anxiety levels duringpainful procedures (p b .05; Prabhakar, Marwah, & Raju,2007). In another study with 2- to 4-year-old oncologypatients, interactive stories (active) were compared withwatching a cartoon movie (passive), and researchers foundthat the active form distraction produced less dist

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