Management of Pediatric Pain and Distress Due to Medical ...

174 II. CROSS-CUTTING ISSUEScoping behaviors, are associated with higher child distress and indicate targets for intervention.Furthermore, there are effective coping skills training interventions to enhanceadults' use of coping-promoting behaviors (e.g., Blount et aI., 1994). For this reason,we strongly advocate teaching adults to use coping-promoting behaviors. If they do so,distress-promoting behaviors will naturally decrease. Training only parents or nurses touse coping-promoting prompts may be adequate for some children to increase their copingand lower their distress. If not, a child training component can be added.AssessnlentMethods for assessing procedural pain and distress include children's self-reports,reports by others, observational measures, and (less frequently) physiological monitoring.We do not believe that there is a "gold standard," with one assessment methodclearly superior to others. Each approach has unique strengths and weaknesses. Ratherthan recommending particular instruments, we refer the reader to scholarly reviews bythe Society of Pediatric Psychology's Evidence-Based Assessment (SPP-EBA) Task Forceon Pain Assessment (Cohen et aI., 2008) and by the Pediatric Initiative on Methods,Measurement, and Pain Assessment in Clinical Trials (Stinson, Kavanagh, Yamada,Gill, & Stevens, 2006; von Baeyer & Spagrud, 2007). There are both overlaps and differencesin these two groups' findings. Some overlaps and differences in the reviews ofobservational measures are discussed by Blount and Loiselle (2009).In addition to assessing pain and distress, we recommend measuring children's copingbehaviors and adults' behaviors during the procedures. These malleable child andadult behaviors help determine the amount of pain and distress children will experience.A recent review of coping inventories by the SPP-EBA Task Force's Workgroup on Copingand Stress should aid in instrument selection (Blount, Simons, et aI., 2008).Preparing Children for Painful Procedures: Information 'ProvisionChildren who are better informed generally have lower distress and are better adjustedduring and after the procedure. Timely, age-appropriate information may provide adegree of exposure that reduces anxiety to potentially frightening medical situations,as well as help the child and parents correctly anticipate what the procedure entails.Also, coping skills training may be conducted in conjunction with information provision(Jaaniste, Hayes, & von Baeyer, 2007b).The type of preparation program is important. O'Byrne, Peterson, and Saldana(1997) surveyed hospital professionals, who rated coping skills, relaxation, and filn1. asthe n1.ost effective preparation procedures, and tours, printed materials, and narrativepreparation as least effective. Of note, the least effective preparation procedures wereendorsed as most frequently used, probably due to their ease of administration and lowcost.Regardless of the method used, preparatory information should be specific ratherthan general, and should include procedural (what will be done) and sensory (what thepatient will experience or feel) information. The optimal tin1.ing of preparation maydepend on the child's age and the nature of the procedure. Children need earlier and

176 II. CROSS-CUTTING ISSUESment for cooperation (Elliott & Olson, 1983), training parents to coach their childrento use coping behaviors (Blount et aI., 1994), and having nurses prompt children towatch cartoon videos (Cohen et aI., 1997). These CBT procedures led to increased useof coping skills, parents' and medical staff members' coaching the children, and reducedpain and distress. Some investigations that included comparisons with pharmacologicalagents found CBT to be as effective as, or more effective than, such agents as diazepam(Valium) (Jay et aI., 1987) or EMLA cream (discussed later) (Cohen et aI., 1999). Also,the combination of CBT with midazolam (Versed) was better than midazolam alone onsome outcome variables (Kazak et aI., 1996). Powers (1999) concluded that CBT metcriteria to be considered as a "well-established treatment" for procedural pain in childrenand adolescents.The beneficial effects of distraction have also been supported in a meta-analysis(Kleiber & Harper, 1999). Furthermore, in a Cochrane Database review, Uman, Chambers,McGrath, and Kisely (2006) studied psychosocial interventions for 2- to 19-yearoldsundergoing needle procedures. The largest effect sizes for treatment versus controlconditions existed for distraction and multicomponent CBT interventions, with hypnosisbeing promising. Promising evidence was also found for other interventions, includinginformation/preparation procedures and nurse coaching to promote child distraction.It is encouraging that the data converge to support the effectiveness of distractionin particular, as well as multicomponent CBT interventions.Virtual reality (VR) is a novel technique for promoting distraction. VR equipmenttypically consists of a head-mounted visual display with auditory input. In a review,Lange, Williams, and Fulton (2006) concluded that the evidence for the use of VR wasstrongest for burns. As an intervention for the pain caused by treating burn injuries,Hoffman, Doctor, Patterson, Carrougher, and Furness (2000) designed Snow World, inwhich a patient moves through an ice world with a video-game-like atmosphere. Painwas reduced in several studies (see www.hitl.washington.edu/projects/vrpain; Hoffmanet aI., 2000). Some limitations of VR include the cost and technical expertise required;the necessity of proper head orientation, which makes it difficult for patients in pronepositions to use; and possible impaired communication with the patient.Effective Use of Distraction ProceduresRegardless of the techniques for promoting distraction, the stimuli or activity should behighly engaging, should be easily performed, and should require an observable response.Observable responses confirm that the coping behavior is being performed. In addition,prompts by adults can help facilitate children's coping and redirect their attention asneeded away from compelling painful or frightening medical procedures. There is someevidence that coping/distracting activities should be matched to the demands of differentmedical phases (Blount et aI., 1990). For example, in one study, distracting conversationsor toy play helped to lower anticipatory distress, but these techniques werereplaced with prompted use of a party blower during painful LPs (Blount et aI., 1994).Using a party blower is simple, is distracting, and requires less thought by the childthan nonprocedural talk during painful LPs would require. During painful procedures,simple distraction techniques that do not exceed a patient's limited attentional capacityat that time are probably more effective.

11. Management of Pediatric Pain/Distress177HypnosisHypnosis involves a state of increased suggestibility, attention, and relaxation. Althoughthe exact mechanism of its action is not well understood, neuroimaging techniquesshow that hypnosis is associated with activation of brain areas consistent with decreasedarousal, visual imagery, and possible reinterpretation of perceptual experiences (Wood& Bioy, 2008). Hypnosis has been used with children experiencing BMAs (Liossi &Hatira, 2003), fracture pain (Iserson, 1999), and postoperative pain and anxiety (Lambert,1996). Uman and colleagues (2006) found hypnosis to be a promising interventionfor self-reported pain in children and adolescents. However, hypnosis may be lesseffective for children under 5 years of age, and some people are not easily hypnotized(Liossi, White, & Hatira, 2006). Challenges in the area include the lack of agreementover operational definitions of hypnosis, as well as the heterogeneity of techniques thathave been used (hypnotherapy, guided imagery, imagery). Future r~search should establishstandardized treatment manuals and should attempt to understand efficacy as afunction of child age and pain type.Combining Information Provision and Attention ManipulationA revised version of our prescriptive model of medical and coping interventions by phaseof medical procedure (Blount et aI., 2003) is presented in Table 11.1. Information provisionincluding both sensory and procedural components should be presented to bothchild and parent during Phase 1, the time prior to the procedure. Most studies indicatethat preparation should occur about a week to several days before the procedure, atleast for older children (Jaaniste et aI., 2007b; Kain et aI., 1996). This duration mayallow a child to mentally prepare for the event or give time for anxiety to diminish viaprolonged exposure to the information. Preparation is also a time for training parents incoping promoting skills and training children to use coping behaviors before and duringmedical treatments. Home practice can also be incorporated.During Phase 2, the child and parent are in the medical setting anticipating the procedure.Rather than introducing new information or dwelling on the upcoming event,playful nonprocedural activities and conversation should be used. These activities helpto lower the child's fear and anxiety before the procedure, and therefore predisposehim or her to lower distress during the next phase (Blount et aI., 1990). As the procedurebecomes imminent and preprocedural instructions are given (e.g., "Climb on thetable"), parents and staff should continue to provide distracting prompts, albeit allowingfor necessary procedural comments (e.g., "a little stick").Phase 3 includes encounter with the painful procedure. Active coaching shouldcontinue. For less painful procedures, distraction techniques such as a continuation ofPhase 2's use of interactive cartoon viewing (Cohen et aI., 1999) may suffice. For morepainful procedures, such as LPs, prompted use of simple coping behaviors that requirelittle cognitive processing (e.g., deep breathing or use of distracting party blowers) maybe preferable. If so, practice during the preparation phase may be necessary to facilitatea child's performance of the desired behaviors. Alternatively, if a trained therapist isavailable, hypnosis may be used (Uman et aI., 2006).

TABLE 11.1. Prescriptive Model of Medical and Coping Interventions by Phase of Medical ProcedurePhase1Phase 2Phase 3Phase 4Phase 5Temporalproximity toprocedureApproach of the procedureAnticipatory phase (in thesetting prior to medicalprocedure)Procedure (during theprocedure)Postprocedure(immediately after theprocedure)Completion (minutes tohours or more after theprocedure)Child experiencesPreparation for upcomingeventAnticipation of imminenteventEncounter with thestimulus and stressRecovery from pain anddistressRecollection andreturn to normal dailyactivitiesProportion ofinformationprovision todistraction• Offer age-appropriatesensory and proceduralinformation to child andparents about the upcomingprocedure.• Provide opportunities to askquestions.• Simple, less painfulprocedures require lesspreparation.• Decrease both informationprovision and the child'sfocus on the upcomingprocedure.• Increase distraction.• Provide primarilydistraction andminimal informationas needed.• Distraction is greatestand informationprovision lowest inthis phase.• Continue mild formsof distraction.• Begin resumption ofnormal activities asappropriate.• Continue resumptionof normal lifeactivities...........-......J00 Copinginterventions• Train child and adults inspecific coping and copingpromotingbehaviors, aswell as when to use them.• Anxiety reduction occursvia exposure to aspectsof the stressor, perhapsthrough coping skillspractice.• These factors increasechild's and parents' sense ofmastery.• Have parents/staff promptchild's use of copingstrategies.• Coping behaviorsmay include movies,nonprocedural talk, toyplay, and other engagingactivities.• Use problem-focused, notemotion-focused, coping.• Supportive, skilled parentsand staff instill confidence.• Coach/promptchild to use copingbehaviors. Copingbehaviors duringpainful procedures areoften simple, such asbreathing or using aparty blower.• Minimize avoidance.• Lower distress/painshould lead to lessclassical conditioning.• Distracting activityor talk can speedreductions in distress,but allow child torecover if needed. Besensitive to child's leadand receptiveness toefforts.• Focus on successfulcoping and instillsense of achievement.• Focus child's attentionon positive copingefforts to promptmemory encoding ofsuccessful coping andnonexaggeration ofdistress.• If pain persists,continue engagingactivities (e.g., movie,talk) as needed if childis receptive.Medical factorsto consider andinterventions tolise• Assess the child's historywith procedures, physicalcondition, painfulness,and other aspects of themedical procedure. Childmay be shown and allowedto handle simple versions ofequipment, such as placingmask for anesthesia.• Use topical or otheranesthetics and, ifnecessary, sedation andanalgesics.• Use less threateningor painful medicalinstruments, such as smallgaugeneedles.• Maintain child-friendly• Use less painfulmedical equipment(e.g., smaller needles)and topical anesthesia.• Keep unexpectedevents to a minimum.• Use pain-reducingmedications as needed.• Use pain-reducingmedications if needed.

11. Management of Pediatric Pain/Distress179Distress diminishes during Phase 4, and less intense attentional redirection activitiescan be used to help speed the child's recovery. It is important to be sensitive to thechild's state, as children may be less responsive after highly painful and distressingevents. Attempting to engage children when they are not likely to be responsive canincrease frustration and distress.During Phase 5, when the procedure is over and the child has recovered, adultsshould praise the child for his or her coping attempts and en1.phasize the good things thechild did. This may help the child remember the event as less distressing and the copingefforts as more beneficial. Chen, Zeltzer, Craske, and Katz (1999) have used a promptedand selective memory-encoding procedure similar to this to help children who mustundergo repeated painful procedures.Preparation for SurgeryChildren's perioperative anxiety is predictive of adverse postsurgical outcomes, includingmore pain, increased emergence delirium, and negative postoperative behaviors(Kain et aI., 2007). Methods for reducing perioperative anxiety include (1) sedativeadministration before surgery, (2) parental presence, (3) preparation and coping skills,and (4) hypnosis (Kain et aI., 2007; Wright, Stewart, Finley, & Buffett-]errott, 2007).Midazolam is a commonly used sedative administered prior to surgery. Doses in therange of 0.25 to 0.50 mg/kg are effective for reducing anxiety within 20-30 minutes(Wright et aI., 2007). However, in some patients midazolam has resulted in longer timeto discharge, longer recovery times, and some maladaptive postsurgical behaviors, suchas nightmares (Wright et aI., 2007).Parental presence during mask anesthesia induction has also been investigated.Although most children prefer a parent to be with them, well-controlled randomizedtrials have not found evidence supporting the benefit of parental presence for reducingchildren's presurgical anxiety (Piira, Sugiura, Champion, Donnelly, & Cole, 2005;Wright et aI., 2007). Instead, it is probable that what parents do is more critical thantheir mere presence (Caldwell-Andrews, Blount, Mayes, & Kain, 2005; Piira et aI.,2005). Investigations are currently underway to assess the impact of adults' behaviorson children's coping and distress during anesthesia induction.Preparation programs for surgery have included information provision, modelingto convey what to expect and how to cope, and training of the child and others in copingprocedures (Blount, McCormick, MacLaren, & Kain, 2008; ]aaniste et aI., 2007a).Kain and colleagues (2007) used a randomized clinical trial to evaluate the effectivenessof standard care, parental presence, oral midazolam at 0.50 mg/kg, and the multicomponentADVANCE program. ADVANCE includes techniques for Q.nxiety reduction,distraction, yideo modeling and education, Qvoiding excessive reassurance, incorporatingparents, parent ~oaching of the child in the holding area through induction, and aparent-directed home-based ~xposure/shapingcomponent to promote mask familiarityand acceptance. Children in the ADVANCE group exhibited lower anxiety in the holdingarea; similar anxiety to that of children in the midazolam condition, and loweranxiety than that of the other two groups during mask induction; and less emergencedelirium, less need for fentanyl for pain relief, and quicker discharge than children in theother three groups following surgery.

11. Management of Pediatric Pain/Distress181Simons, and Hayutin (2008) used the Infant Version of the CAMPIS (CAMPIS-IV) toconduct a sequential analytic investigation of parent, nurse, and infant behaviors thatinfluenced 2- to 20-month-olds' level of crying following immunizations. Strong supportwas found for the benefits of sucking a bottle or pacifier, holding an infant in a belly-tobellyposition, nonprocedural talk to the infant, and having the infant play with objects.Some support was found for bouncing, rocking, and patting the baby. No support wasfound for adults' reassurance, apologies, or empathic statements to an infant; there waseven some indication that reassurance might be detrimental. Behavioral observationstudies using such instruments as the CAMPIS-IV and the MAISD may inform thedevelopment of new interventions or refine existing ones.Pharmacological Management of Procedural Pain and DistressWhen choosing pharmacological interventions for procedural pain and anxiety, thepatient's age as well as the invasiveness, painfulness, and duration of the proceduremust be considered. Some procedures, such as venous access, routinely require local ortopical anesthetics; others, whether painful (e.g., LP) or nonpainful (e.g., magnetic resonanceimaging, or MRI), may require potent sedatives and analgesics. It is importantfor psychologists and other nonmedical professionals working in the area of acute painmanagement to have a basic familiarity with pharmacological approaches.Topical and Local AnestheticsTopical and local anesthetics are the drugs of choice for siniple procedures such asvenipuncture, venous access, laceration repair, subcutaneous port access, and dermatologicalprocedures (Zempsky, 2006). Among these agents, lidocaine injected subcutaneouslyis effective for decreasing pain from venous access, dermatological procedures,and laceration repair. Lidocaine can be injected with little pain if the technique includesbuffering with bicarbonate, warming it before injecting, and injecting slowly with asmall-gauge needle.Topical anesthetics allow for needleless dermal anesthesia. However, each topicalagent has some shortcoming, such as the time required to work or lack of adaptabilityto different procedures (Zempsky, 2006). The most extensively studied of these agents,Eutectic Mixture of Local Anesthetics (EMLA) cream, has been shown to be effectivefor a variety of procedures, including venous cannulation, venipuncture, immunization,subcutaneous port access, and LPs (Uhari, 1993). EMLA is safe when used appropriately,even in premature infants. Unfortunately, EMLA requires 60 minutes to provideadequate anesthesia. EMLA can be used for nonemergent procedures when properlyanticipated (Zempsky, 2006).LMX4 is a liposomal lidocaine cream-based formulation silnilar to ENILA; however,it provides efficacy in only 30 minutes. LMX4 has not been well studied for proceduresother than venous access, and its safety in children under age 3 has not beenestablished. In many centers, it is used interchangeably with EMLA (Kleiber, Sorenson,Whiteside, Gronstal, & Tannous, 2002).Synera, a patch containing lidocaine and tetracaine, includes a heating system thataccelerates transcutaneous delivery and analgesic effect within 20-30 minutes. Synera is

182 II. CROSS-CUTTING ISSUESsafe and effective for venous access and dermatological procedures (Sethna et aI., 2005).Tetracaine and heat both cause vasodilatation, which may facilitate venous access.Iontophoresis promotes the rapid transfer of lidocaine, which is positively charged,into the skin under the influence of electric current (Zempsky, Anand, Sullivan, Fraser,& Cucina, 1998). Lidocaine iontophoresis is superior to EMLA as a topical anestheticfor venous access and does not produce systemic lidocaine levels during routine use.However, some patients experience tingling, itching, or burning with this technology,which has limited its acceptance.Vapocoolant sprays, such as ethyl chloride and flourimethane, work in about 30seconds and are inexpensive. However, the evidence regarding their efficacy for injectionpain and venous access procedures is conflicting (Costello, Ramundo, Christopher,& Powell, 2006; Reis & Holubkov, 1997). Also, some children find their cold sensationunpleasant.Zingo is a product that utilizes a prefilled needleless compressed helium gas systemto accelerate powdered lidocaine into the skin. Zingo is safe,- and anesthesia is achievedpainlessly in about 1 minute. Studies of Zingo have not been done for injections, butshow efficacy for both venipuncture and venous access procedures (Zempsky, Robbins,Leong, & Schechter, 2008).LET, used exclusively for laceration repair, is a combination of lidocaine, epinephrine,and tetracaine that can be made by a hospital pharmacy. When placed in a wound20-30 minutes prior to laceration repair, LET provides excellent anesthesia for faciallacerations, and can be used to reduce the pain of lidocaine infiltration for extremitylacerations (Ernst et aI., 1995). LET is safe, but should not be used on mucous membranesor digits.Procedural SedationIn choosing sedation agents, it is important to consider whether the procedure will bepainful (e.g., BMA, fracture reduction), less painful but anxiety-producing (e.g., voidingcystourethrogram [VCUG], laceration repair with local anesthesia), or nonpainful butrequiring motionlessness (e.g., NIRI). Guidelines describe the appropriate n'lonitoring achild should receive during and after procedural sedation (American Academy of PediatricsCommittee on Drugs, 2002; American Society of Anesthesiologists Task Force,2002). Sedation carries risks that include hypoventilation, apnea, airway obstruction,aspiration, laryngospasm, and cardiopulmonary impairment. Although any of the commonlyused agents described below can result in deep sedation, they are presented inorder of targeted endpoint from minimal to deep sedation. For a full review, see Kraussand Green (2006).Midazolam (Versed) is an anxiolytic agent that can be given intravenously, orally,nasally, or rectally. It can be used alone (VCUG, preoperative anxiety), as an adjunctwith a local or topical anesthetic (laceration repair, LP), or with an analgesic (fracturereduction, BMA) to reduce anxiety. It does not provide motionlessness and can lead todisinhibition. Side effects include respiratory depression, airway obstruction, and paradoxicalexcitement.Nitrous oxide has anxiolytic and analgesic properties that make it useful aloneor in conjunction with a local Of topical anesthetic for a variety of procedures (dental,VCUG, laceration repai f, sexual abuse exam). It is inhaled via a mask. Side effects

11. Management of Pediatric Pain/Distress183include respiratory and myocardial depression. Nitrous oxide may be a teratogen, andtherefore a scavenger system must be available for collecting waste gases.Chloral hydrate is a hypnotic agent given orally or rectally. It has no analgesicaction, but does provide motionlessness for diagnostic imaging or electroencephalography.Problems with chloral hydrate include its inconsistent action, a high percentage ofsedation failures, and a long duration of action. Side effects include respiratory depressionand agitation.Barbiturates (methohexital, pentobarbital), usually reserved for diagnostic imagingprocedures, provide sedation and motionlessness, but no analgesic action. Side effectsinclude respiratory depression, hypotension, paradoxical exciten1.ent, and impairedmood.Opiates (fentanyl, sufentinyl, morphine, hydromorphone) are excellent analgesicsthat can be used along with such agents as propofol or midazolam during sedation. Fentanyl,a semisythetic opioid, is the most commonly used of these agents for this purpose.It has a shorter onset and half-life and is n1.ore potent than morphine or hydromorphone.Side effects of opiates include respiratory depression, nausea, vomiting, and itching.Ketamine is a dissociative and an excellent anesthetic. It is used for painful proceduressuch as fracture reduction, large or complex laceration repairs, and chest tubeplacements. Ketamine causes nystagmus and a trance-like appearance, which often scareparents observing the procedure. Potential side effects include laryngospasm, raisedintracranial pressure and intraocular pressure, disinibition, and agitation.Propofol is an anesthetic agent with a rapid onset and offset that is increasinglybeing used for various procedures (e.g., fracture reduction, imaging, colonoscopy) bynonanesthesiologists. It has no analgesic action, so it must be used in conjunction withan analgesic during painful procedures. Side effects include respiratory depression andhypotension.Integration of Psychological and Pharmacological ApproachesPediatric procedural pain and distress include both psychological and physiologicalcomponents, and it is often necessary to approach this area in an integrated way. In theprescriptive model presented in Table 11.1, we describe the medical factors to consider,along with interventions that are appropriate at the different phases. In addition toassessment during Phase 1, medical management of procedural pain and distress occursprimarily in the time periods in close temporal proximity before and after (and, of course,during) procedures. For simple procedures, topical anesthesia is sufficient, whereas formore complicated interventions, sedation may be required. Effective psychological interventionmay reduce the need for or amount of anesthetic or sedative agents, primarilythrough lowering preprocedural anxiety and distracting attention from painful stimuli.As noted earlier, several studies have shown psychological approaches in some cases tobe as effective as, or more effective than, such pharmacological agents as EMLA (Cohenet aI., 1999), diazepam (Jay et aI., 1987), and midazolam (Kain et aI., 2007). There isalso evidence that combined psychological and pharmacological approaches are moreeffective than pharmacological agents alone (Kazak et aI., 1996). Conversely, effectivetopical anesthesia that reduces pain may reduce children's anxiety about subsequentprocedures. Developing optilllal combinations of n1edical and psychological approachesto managing procedural pai nand distress will be a priority for future research.

184 II. CROSS-CUTTING ISSUESCommentary and Future DirectionsPerhaps because pediatric procedural pain and distress are so compelling, considerableresearch attention has been devoted to this area over the last three to four decades.Pioneering researchers have made notable advances in both psychosocial and medicalapproaches to addressing this problem. In many ways, this is one of the more developedareas of pediatric psychology: Technologies for assessment and treatment of pain nowexist for populations from premature infants through adolescents, and across a host ofpainful or frightening procedures.As any field matures, new frontiers for research may shift from stunning innovationto more precise refinement of assessment and intervention techniques, as well asbetter application and dissemination of established principles. In many ways, the fieldof procedural pain n1.anagen1.ent is at that juncture. A firm foundation has been laid andshould be built upon. Creativity is needed, and often this may take the form of pullingtogether different bodies of existing knowledge in unique ways or implementing what isknown into additional areas of pediatric health care.Future research should include additional attention to social influences on preproceduralpain and anxiety in different populations of children. For example, research iscurrently being conducted on how voice quality or intonation may interface with vocalcontent (e.g., reassuring comments) to facilitate distress. In addition, the influence ofsocial interactions is being assessed in new populations, including patients with functionalabdominal pain (Walker et aI., 2006), those undergoing mask anesthesia induction(Kain et aI., 2007), and infants (e.g., Piira et aI., 2007). Results from these studiescan help inform research with additional pediatric populations whose acute, episodic,and persistent pain may be influenced by similar factors.Dissemination of medical and psychosocial approaches for procedural pain managementfrom research to applied clinical settings is an ongoing issue. As in many otherfields, bringing about enduring change in health care practices in applied settings canbe problematic, or at the very least, gradual. Collaboration with medical professionalsin applied settings, publishing in different psychological and medical journals to reacha wider audience, and presenting new research at local meetings that may be morelikely to attract practitioners may help facilitate translation of research into practice.Also, it is possible that pediatric pain researchers may benefit from collaboration withindustrial-organizational psychologists in their dissemination efforts. Furthermore, theuse of novel methods of intervention, such as interactive computer programs for trainingbasic coping skills to parents and children seeking medical treatment, may be a way tocircumvent logistical obstacles in busy clinic settings.ReferencesAmerican Academy of Pediatrics Committee on Drugs. (2002). Guidelines for monitoring andmanagement of pediatric patients during and after sedation for diagnostic and therapeuticprocedures: Addendum. Pediatrics, 110, 836-838.American Society of Anesthesiologists Task Force on Sedation and Analgesia by Nonanesthesiologists.(2002). Practice guidelines for sedation and analgesia by nonanesthesiologists.Anesthesiology, 96,1004-1017.

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Handbook ofPediatric PsychologyFOURTH EDITION .Edited byMICHAEL C. ROBERTSRIC G. STEELE~THE GUILFORD PRESSNew York London