Venous access Venous access has been identifi ed as one of the medical procedures most fear ed by children (Carlson et al., 2000 ). In one of the few studies comparing distraction int erventions, MacLaren and Cohen ( 2005 ) found that passive distraction (viewing movies) was more eff ective than active distraction (responding to games on an elec- tronic toy) durin g pediatric venous access. Bellieni et al. ( 2006 ) also found that passive distraction (wa tching a TV cartoon) was more eff ective than active distraction during venepuncture. Th at said, a study evaluating children \200\231s pain tolerance during a cold pres- sor suggest s that active distraction (playing a videogame) might be more eff ective than passive distr action (watching a videogame) (Wohlheiter and Dahlquist, in press). Several studies support the effi cacy of audiovisual distraction techniques, through the fo rm of animated cartoons, in diverting children \200\231s attention from venepuncture pain. Yoo et al. ( 2011 ) found an animation distraction intervention eff ective in reducing self -re- ported pain, behavioral pain responses, and serum cortisol and glucose levels in presc hool-aged children during venepuncture in Seoul, Korea. Wang et al. ( 2008 ) found cartoon videos equally eff ec- tive as other routine psychological interventions (i.e. explaining, therapeutic touch, encouragement, and guided imagery) in reduc- ing self-reported pain, enh ancing patient cooperation, and height- ening the success rate of venepuncture procedures. Researchers also suggest that animation distraction is both simple to administer and could be easily integrated into health care settings. Berberich and Landman ( 2009 ) included distraction in a package to reduce pain in pre-scho olers receiving immunizations. Th e inter- vention included a multipronged arm gripper, top ical analgesic, and a vibrating instrument on the opposite arm. Th e children were encourag ed to guess when the vibrating device reached their arm. Results supported the intervention across measures (self-report scores, p <0.0013; parent report scores, p <0.0002; observati onal coding scores comparing baseline to completion of immunization series, p <0.0001), but it is unclear which are the critical ingredients in package interventions such as this (Co hen, 2010 ). Although studies remain less conclusive about caregiver partici- pation, some suggest that distraction education for parents prior to venepuncture may be valuable (Kleiber et al., 20 01 ). Kleiber et al. ( 2001 ) compared parent \200\223child dyads in a control group to tho se in a distraction education group across two phases of venepuncture, procedural preparati on and needle insertion. Parents in the dis- traction education group employed signifi cant ly more distraction during both phases compared to parents in the control group and childre n in the distraction condition exhibited less distress during the two procedural phases tha n children in the control condition. In a review of the literature, Cohen ( 2008 ) suggeste d that distrac- tion is recommended for pediatric venous access, particularly for children aged 7 years or younger, due to its empirical support, min- imal risks, and cost- and time- eff ectiveness. Burn debridement and treatment Childhood burns represent one of the most ph ysically and emotion- ally traumatic injuries (Benjamin and Herndon, 2002 ; Hettiaratchy an d Dziewulski, 2004 ), which oft en result in long-standing pain and distress (Fitzgerald, 2 005 ; Passaretti and Billmire, 2003 ; In a systematic review of 20 randomized controlled trials (RCTs), Chambers et al. ( 2009 ) determined that both child-directed (e.g. cartoons, music) and nurse-led (e.g. trained to d istraction with movies or toys) distraction were eff ective in mitigating pain and distress during child immunizations, whereas evidence remained inconclusive for parent-led (e.g. tr ained to distract with movies or toys) distraction. Chambers et al. noted that distraction with age- appropriate toys was the only psychological intervention examined in the review t hat can be applied to all age groups due to the ability to select toys suitable for infants , children, or adolescents. A review by DeMore and Cohen ( 2005 ) concluded that distractio n is both a time- and cost-effi cient strategy for immunizations and that it eff ectively r educes children \200\231s injection pain. Although a variety of distracters were used in th e studies evaluated, the most commonly employed distraction stimuli were playing cartoon mo vies, non- procedural talk, and having the child listen to music. Distraction strategies th at either required an overt response from the child or involved multiple sensory modalities were most eff ective. SECTION 7 psychosocial interventions 556 Schechter et al., 1993 ). Increasing research has focused on evaluat- ing behavioral approa ches for pain management for burn treat- ment procedures (e.g. skin debridement; de Jong et al., 2007 ) given that pharmacological analgesic methods oft en prove inadequate (e.g. Hof f man et al., 2004 ; for a review, see Morris et al., 2009 ). In a study of music distraction, researchers found this treatment eff ective in lowering an xiety in children with cancer receiving lum- bar punctures (Nhan Nguyen et al., 2010 ). Alt hough not described as distraction, commonly used hypnosis and imagery techniques are argua bly forms of internally shift ing attention from a noxious stimulus to another stimulus. As an example, in a study of 6- to 16-year-olds receiving venepuncture as part of their cance r care, Liossi et al. ( 2009 ) found self-hypnosis superior for pain and anxi- ety relief a s compared to control and attention conditions. A sys- tematic review of the literature ind icated that hypnosis is a viable intervention for procedural pain in pediatric oncology pat ients (Richardson et al., 2006 ). Further discussion on hypnosis can be found elsewhere in this volume (Liossi et al., Chapter 54 ). Th e distraction literature for burn treatment procedures oft en involves sophisticated \200\224and potentially highly engaging \200\224interven- tions (e.g. virtual reality; Hoff man et al., 2004 ). Th is is likely related to the rationale that it is challenging to dis tract a child from the severe pain that is associated with burn treatment pain. To exem- pl ify, in comparison to standard distraction and hand-held video game distraction, multi-moda l distraction used for procedural preparation and distraction during dressing changes signi fi cantly reduced pain and the duration of three dressing changes among children in a pedia tric burns outpatient clinic (Miller et al., 2010 ). Th is hand-held device eff ectively en gaged children in an interactive procedural preparation story or a touch and fi nd interact ive distrac- tion story during the dressing change procedure. In a study of chil- dren \200 \231s distress related to burn-dressing changes, Mott et al. ( 2008 ) compared \200\230aug mented reality \200\231 (akin to virtual reality although uses overlays of virtual images o nto the actual world) to basic cognitive therapy. Parents \200\231 ratings and children \200\231s self-reports indicated that the augmented reality distraction was superior to con trol for burn treatment pain relief. Conclusion Given the vast array of distraction techniques and study meth- odology reported, meta-analyzes and review studies present an integrated overview of strengths and limitatio ns in the literature, providing direction for future research. Koller and Goldman ( 2011 ) critically assessed studies evaluating distraction for children rang- ing from infant to yo ung adults undergoing medical procedures and found support for such interventions, while al so address- ing important gaps in the literature. A systematic review of RCTs employing psy chological interventions for children and adolescents during needle-related procedures foun d distraction to have one of the largest eff ect sizes in managing procedural pain and dist ress compared to control conditions (Uman et al., 2008 ). Specifi cally, studies suffi cien tly support the use of distraction for self-reported pain, a combination of distraction and suggestion for self-reported pain, a combination of nurse coaching and distraction for dis tress assessed behaviourally, and a combination of parent positioning (e.g. instructing the parent where to sit and how to hold the child) and distraction for distress using observer reports. A meta-analysis examining the mean eff ect sizes of distraction on children \200 \231s distress behavior and self-reported pain during medical procedures con- cluded that a lthough distraction had a positive eff ect on children \200\231s distress behavior, moderat or variables infl uenced the eff ect of distraction on children \200\231s self-reported pai n intensity. Specifi cally, the amount of explained variance signifi cantly increased aft e r con- trolling for child age and type of procedure, suggesting that other potential modera tors may also infl uence this relation (Kleiber and Harper, 1999 ). Distraction, in the form of immersive virtual reality, has also been shown eff ective as an adjunctive analgesic for pediatric burn patients (Schmitt et al., 2011 ). Participants ran domly assigned to the immersive virtual reality group (i.e. SnowWorld virtual envi- ronment ) reported signifi cant decreases in pain ( p <0.05) and improved aff ect when performing r ange-of-motion exercises on the fi rst day of the study, which persisted across the 5 days of physical therapy sessions. Similar positive results were demonstrated by Das et al. ( 20 05 ) in a study of virtual reality distraction for 5- to 18-year- olds undergoing burn trea tment. Similarly, Hoff man et al. ( 2000 ) showed that virtual reality distraction reduced pain scores, anxiety, and time spent thinking about pain for two adolescents undergo- ing w ound care for severe burns. Researchers in this area suggest that distraction should be tai lored to individual patient needs, that the potency or engaging quality of the distraction should match the severity of the procedural pain, and lower cost and greater portabil- ity would provide more widespread dissemination of the interven- tions (Hoff man et al., 2011 ) . Cancer treatments During cancer treatment, children undergo multiple invasive medical proce dures including venous port access, lumbar punc- ture, and venepuncture; the treatments are oft en described as the most distressing part of the disease (Hedstrom et al., 2003 ). Des pite advances in pharmacological approaches for pain manage- ment, there continues to be a need for additional pain and anxiety relief (e.g. Varni et al., 2004 ). A number of distrac tion interven- tions have been eff ective for the procedures faced by this popula- tion. Fo r example, Gershon et al. ( 2004 ) found that a virtual gorilla distraction exhibit eff ect ively lowered distress in a small sample of 7- to 19-year-olds with cancer undergoing port access procedures. Windich-Biermeier et al. ( 2007 ) had 5- to 18-year-old oncology patient s select from a variety of distraction stimuli (e.g. books, bub- bles, hand-held games) and showed that distraction lowered their fear and distress during port access and venous acce ss procedures. Although most reviews support distraction as an effi cacious psy- chological intervention f or pediatric procedural pain, study limita- tions and recommendations for future research a re also presented. Many researchers fail to elaborate on the randomization procedure used o r the nature of participant attrition, which limits the value of any signifi cant results ( Uman et al., 2006 ). Due to the mini- mal number of RCTs directly comparing distraction met hods, it remains challenging to discern which interventions are most eff ec- tive, particul arly given their varying degrees of patient engagement. Moreover, many researchers also inc orporate multiple distraction approaches in the intervention design, which makes it diffi c ult to uniquely assess specifi c unique distraction techniques. Established methods must al so be evaluated against novel interventions longi- tudinally, as the novel interventions ma y become less effi cacious as child habituation gradually increases. In addition to account ing for a child \200\231s prior exposure to a particular form of distraction, future CHAPTER 53 procedural pain distraction 557 research should also address patient preferences and other child- specifi c variables (e.g. temperament, past medical experience). Other areas of improvement include the incorporatio n of data to assess patients \200\231 and health care providers \200\231 personal experienc es with distraction, recruiting larger sample sizes, examining both the short- and long-ter m eff ects of distraction, and using pain meas- ures that have established validity. Finall y, the paucity of objective measures of time spent actively engaged in distraction may also infl uence fi ndings deemed signifi cant (Koller and Goldman, 2011 ). Whereas distraction appears to be eff ective for pre-schoolers and school-age children, suffi cient evidence to support the effi cacy of distraction for procedural pain in infants has not been establish ed (Cramer-Berness, 2007 ; Pillai Riddell et al., 2011 ). and several Anime comic books. Th e nurse begins playback of the movie and engages Johnnie in conversation about the fi lm in advance of the medical procedure to decrease anticipator y anxiety (e.g. Cohen, 2008 ). Johnnie \200\231s parents join the conversa- tion and furthe r encourage distraction, which is expected (e.g. Cohen et al., 1997 ). Given that Johnnie h as undergone numer- ous port-access procedures, information about the procedure is minimize d (for a review, see Jaaniste et al., 2007 ). When Johnnie displays or reports distress or pain, the nurse and parents briefl y and neutrally acknowledge it but immediately re-engage him in the movie; and when the port-access procedure is complete, the nurse will continue to employ distraction strategies in order to minimize post-procedure distress. Consistent w ith recommen- dations in the literature (Cohen et al., 2001 ), Johnnie \200\231s hope- full y low to moderate anxiety and pain ratings might be retained in his medical chart so that h e might review them at his next port-access procedure in order to decrease potentially dist orted anticipatory anxiety. In summary, there are ample data to support the general argu- ment that distraction is an e ff ective intervention for children \200\231s acute painful medical procedures (e.g. Kleibe r and Harper, 1999 ). Th e literature supports a variety of distraction approaches used acr oss routine (e.g. immunizations) and more invasive (e.g. burn debride- ment) pediatric proc edures and with a range of patient popula- tions. However, a closer inspection of the data reveals a complicated story with a number of variables (e.g. age, distraction technique, ty pe of procedure) infl uencing the success of distraction for chil- dren \200\231s anxiety a nd pain mitigation. Future studies in distraction for pediatric procedural pain might more closely identify the mecha- nism of action. For example, it remains unclear as to whether t he induction of a positive mood, the involvement of multiple sensory modalities, or other a spects (e.g. developmentally appropriate tech- nique, engagement in distraction, parental a ttention during distrac- tion) is critical. In fact, data suggest that mood and attention e ach might infl uence pain, but these two avenues do so in diff erent ways (Villemure and Bu shnell, 2002 ). In addition, the literature remains largely equivocal about matching distra ction to patient characteris- tics, which is becoming increasingly important as pressure mo unts to provide tailored treatment (Department of Health and Human Services, n.d.). For exa mple, a handful of studies a number of years ago explored matching distraction to avoidance , blunter, or repres- sor coping style, but the fi ndings were inconsistent (e.g. Christian o and Russ, 1998 ; Fanurik et al., 1993 ; Smith et al., 1989 ). 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CHAPTER 54 Hypnosis and relaxation Christina Liossi , Leora Kuttner , Chantal Wood, and Lon nie K. Zeltzer Introduction Psychological approaches to symptom management are among the oldest and are an intrinsic part of medical practice in every cul- ture. Suggestive therapy is probably the oldest of all therapeutic methods and hypnosis under various names has been used for as lon g as records have been kept. Despite the fact that research on clinical hypnosis with child ren is still in an early stage of develop- ment and the child hypnosis literature is predom inantly composed of anecdotal case histories and uncontrolled research studies, one of the best-documented uses of hypnosis is in the treatment of pae- diatric pain where hypnosis ha s achieved status as an evidenced- based/empirically supported intervention. In this chapte r, the current research literature and clinical practice regarding the use of hypnosis in p ediatric pain management will be discussed. First hypnosis is defi ned and theoretical conc eptualizations are briefl y discussed. Second, our current understanding of the mechanisms of hypnotic analgesia is presented. Th ird the research evidence for the effi cacy of hypno sis in the control of acute and chronic paedi- atric pain is reviewed; in both sections rel evant clinical techniques are discussed. Following, a description and discussion of diff er ent relaxation techniques and the evidence for their effi cacy in acute and chronic pain ma nagement is presented. Th e chapter concludes with an attempt to summarize and evaluate the existing literature and make suggestions for future studies and clinical practice. Box 54.1 Hypnotic induction and deepening techniques for young people Favorite activity Imagine building a Lego house at home; just let yourself feel that way no w. Arm levitation Pay special attention to your hand and arm. Something inter- esting and stra nge is going to happen to them \200 you become aware of how warm or cold your arm is, of little muscles in your hand and arm that twitch ever so slightly \200 and now perhaps you would like to imagine \200 that I am fastening a string around your wrist \200 fastene d to the other end of the string \200 over there on the ground \200 lies a balloon that is not yet blown up \200 what color is it? \200 that \200\231s right it is bright yell ow \200 now the balloon is being fi lled with helium \200 you can see the balloon lift off the ground and rise, rise higher and higher \200 the string around your wrist becomes taut \200 watch what happens to the arm \200 yes, it is pulling the hand and arm up \200 Ascending cloud You are relaxing on a warm sunny day, looking at a clear blue sky \200 yo u see a fl uff y white cloud fl oating gently down towards you \200 Hop on the cloud \200 the cloud starts going up again \200 you feel yourself relaxing and drift ing deepe r and deeper into tranquility as you remain immersed in the cloud \200 that goes higher a nd higher \200 you fl oat at a comfortable height.