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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.
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