of involving child life specialists in pediatric pain care, and for studies to further our understanding of how child life special- ists can provide maximum benefi t to children in p ain and their families. References Alcock , D. S. , Feldman , W. , Goodman , J. T. , McGrath , P. J. , and Park , J . M. ( 1985 ). Evaluation of child life intervention in emergency department suturing . Ped iatr Emerg Care , 1 , 111 \200\223115. Children/youth with chronic physical or mental illness are at risk of social isolation whic h can impact self-esteem, self-perception and overall coping with diagnosis and treatment. Th e advent of Starbright World (< http://www.starbrightworld.org/default_login. aspx?Re turnURL=%2fh ome.aspx >) and American Academy of Pediatrics Child Life Council and Committee on Hospital Care. ( 2006 ). Child life services . Pediatrics , 118 , 1757 \200\2231763. Anonymous . ( 1959 ). Th e we lfare of children in hospital . Br Med J , 1 , 166 \200\223169. Upopolis \204 (< https://www.upopolis.com/webconcepteur/web/ upopolis >) are examples of online Intranet support programs that youth with chronic illness can meet others in similar situations while in a safe, closed system, on the Internet. Both programs con- tain health information written for children and youth in devel- opmentally appropriate language. Stud ies of Starbright World indicate improvements in mood and pain responses in children/ yo uth and nearly signifi cant results for anxiety (Davis et al., 2004 ; Rode et al., 1998 ). Bandstra , N. F. , Skinner , L. , LeBlanc , C. , Chambers , C. T. , Hollon , E. C. , Brenna n , D. , et al . ( 2008 ). Th e role of child life in pediatric pain management: a survey o f child life specialists . J Pain , 9 , 320 \200\223329. Barnes , P. ( 1995 ). Th irty yea rs of play in hospital. Int J Early Child , 48 \200\22353. Blount , R. L. , and Loiselle , K. A. ( 2009 ). Behavioral assessment of pediatric pain . Pain Res Manag , 14 , 47 \200\22352. Bowlby , J. ( 1952 ). Maternal care and mental health . Geneva : World Health Organization . Breiner , S. ( 2003 ). An evidence-based eating disorder program . J Pediatr Nurs , 18 , 75 \200\22380. Th e use of high-defi nition and augmentative reality will likely launch technology to a ne w level of interactive capacity, with grow- ing evidence supporting the effi cacy of these approaches for the management of pain in children (Kipping et al., 2012 ; Miller et al., 20 09 ). Th is may have even more success in distracting children from distressing or painful stimuli. Research into the use of all of these devices has barely begun; however, clinicall y there is a great deal of excitement about the perceived success of such applica- tions in the area of teaching, preparation, procedural support, and expressive activities. Brewer , S. , Gleditsch , S. L. , Syblik , D. , Tietjens , M. E. , and Vacik , H. W. ( 2006 ). Pediatric anxiety: child life intervention in day surgery . J Pediatr Nurs , 21 , 13 \200\22322. Browning , D. and Stroud , M. A. ( 2008 ). Pediatric ED seeks to touch all the bases: advanced courses prepare staff . ED Manage , 20 , 77 \200\22379. Campbell , L. A. , Kirkpatrick , S. E. , Berry , C. C. , and Lamberti , J. J. ( 1995 ). Pre paring children with congenital heart disease for cardiac surgery . J Pediatric Psychol , 2 0 , 313 \200\223328. Cavender , K. , Goff , M. D. , Hollon , E. C. , and Guzzetta , C. E. ( 2004 ). Parents \200 \231 positioning and distracting children during venipuncture: eff ects on children \200 \231s pain, fear, and distress . J Holist Nurs , 22 , 32 \200\22356. Chernoff , R. G. , Ireys , H. T. , DeVet , K. A. , and Kim , Y. J. ( 2002 ). A randomized, controlled trial of a community-based support program for families of children with chronic illness: pediatric outcomes . Arch Pediatr Adolesc Med , 156 , 533 \200\223539. Conclusion Child life specialists play an important role in the assessment and management o f pain in children in a variety of settings through- out the hospital as well as other heal th care settings. Th eir exper- tise and unique relationship with the child and family can provide a rich source of information to the interdisciplinary medical team in order to prom ote eff ective pain assessment and management and to provide the best overall collaborative and eff ective care for children. Child life specialists make major clinical contributions in terms of their delivery of non-pharmacological pain manage- ment strategies, with a foc us on preparation, rehearsal, behav- ioural and cognitive distraction, and physical interve ntions such as positioning for comfort. Despite their considerable involvement in pain asse ssment and management, it has only been in recent years that empirical research on the role of child life specialists in pediatric pain had begun to emerge in the literature. Until f urther research emerges, the use of theoretical frameworks and evidence based literature co ntinues to be the foundation of child life clinical practice. It is critical for the profes sion to continue to question the historical assumptions related to child life interven- tio ns and seek best evidence and research to ensure effi cient and eff ective practice. Child Life Council. ( 2002 ). Offi cial documents of the child life council . Rockville, MD : Child Life Council . Child Life Council. ( 2012 a). Th e child life profession . Available at: < http:// www.chi ldlife.org/Th e%20Child%20Life%20Profession/ > (accessed 17 April 2012). Child Life Council. ( 2012 b). CCLS directory . Available at: < http://ams. childlife.org/members_online/members/CCLS_Directory.asp > (accessed 17 April 2012). Cregin , R. , Rappaport , A. S. , Montagnino , G. , Sabogal , G. , Moreau , H. , and Abular rage , J. J. ( 2008 ). 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Th ere is a need for interprofessional collaboration, training, and research in the fi eld of pediatric pain in an eff ort to trans- late the knowledge that exists into daily practic e. However, it will also be important for future studies to address the added benefi t Glasrud , P. H. , and Feigal , R. J. ( 1984 ). Child life and children \200\231s dentistry: broadening our scope of concern . Child Health Care , 12 , 143 \200\223147. SECTION 7 psychosocial interventions 552 Plank , E. ( 1962 ). Working with children in hospitals: a guide for the professional Gursky , B. , Kestler , L. P. , and Lewis , M. ( 2010 ). Psychosocial intervention on proce dure-related distress in children being treated for laceration repair . J Dev Behav Pediatr , 31 , 217 \200\223222. team (3rd edn). Cleveland, OH : Western Reserve University . Prugh , D. G. , Staub , E. M. , Sands , H. H. , Kirschbaum , R. M. , and Lenihan , E. A. ( 1953 ). A study of the emotional reactions of children and families to hospitalization and illness . Am J Orthopsychiatry , 23 , 70 \200\223106. Hicks , M. ( 2008 ). Child life beyond the hospital . Rockville, MD : Child Life Council Inc . Hospital Play Specialist Association of Aotearoal/New Zealand. ( 2012 ). Offi cial Document s and forms . Available at: < http://www.hospitalplay.org.nz/ online/offi cial_documents.cs n > (accessed 17 April 2012). Rode , D. , Capitulo , K. L. , Fishman , M. , and Holden , G. ( 1998 ). Th e therapeutic use of technology . Am J Nurs , 98 , 32 \200\22335. Rubin , S. ( 1992 ). What \200\231s in a name? Child life and the play lady legacy . Child Jaaniste , T. , Hayes , B. , and von Baeyer , C. L. ( 2007 ). Providing children with infor mation about upcoming medical procedures: a review and synthesis . Clin Psychol Sci Pract , 14 , 124 \200\223143. Health Care , 21 , 4 . Shelton , T. and Stepanek , J. ( 1994 ). Family-centered care for children needing speciali zed health and development services (3rd edn). Rockville, MD : Child Life Council Inc . Jessee , P. and Gaynard , L. ( 2009 ). Paradigm of play . In R. W. Th ompson , (ed.) Th e h andbook of child life: a guide for pediatric psychosocial care , pp. 136 \200\223159. Sprin gfi eld, IL : Charles C. Th omas . Sinha , M. , Christopher , N. C. , Fenn , R. , and Reeves , L. ( 2006 ). Evaluation of nonp harmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department . Pediatrics , 117 , 1162 \200\2231168. Jun-Tai , N. ( 2008 ). Play in hospital . Paediatr Child Health , 18 , 233 \200\223237. Ki pping , B. , Rodger , S. , Miller , K. , Kimble , R. M. ( 2012 ). Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized control led trial . Burns , 38 , 650 \200\223657. Skinner , L. and LeBlanc , C. ( 2002 ). Child life assessment intervention plan (CLAIP). 2n d version . Halifax, NS : Child Life Services, IWK Health Center . Kleiber , C. , McCarthy , A. M. , Hanrahan , K. , Myers , L. , and Weathers , N. ( 2007 ). Development of the distraction coaching index . Child Health Care , 36 , 219 \200\223235. Spaff ord , P. A. , von Baeyer , C. L. , and Hicks , C. L. ( 2002 ). Expected and reported pain in children undergoing earpiercing: a randomized trial of preparation by parents . Beh avior Res Th er , 40 , 253 \200\223266. Koller , D. ( 2007 ). Child Life Council evidence-based practice statement: preparing child ren and adolescents for medical procedures . Rockville, MD : Child Life Council . Sparks , L. A. , Setlik , J. , and Luhman , J. ( 2007 ). Parental holding and positioning t o decrease IV distress in young children: a randomized controlled trial . J Pediatr Nurs , 22 , 440 \200\223447. Koller , D. ( 2008 a). Child Life Council evidence-based practice statement. child life ass essment: variables associated with a child \200\231s ability to cope with hospitalization . Rockville, MD : Child Life Council . Spitz , R. A. ( 1945 ). Hospitalism; an inquiry into the genesis of psychiatric conditions in early childhood . Psychoanal Study Child , 1 , 53 \200\22374. Koller , D. ( 2008 b). Child Life Council evidence-based practice statement: therapeutic pl ay in pediatric health care: the essence of child life practice . Rockville, MD : Child Lif e Council . Stephens , B. K. , Barkey , M. E. , and Hall , H. R. ( 1999 ). Techniques to comfort childr en during stressful procedures . Accid Emerg Nurs , 7 , 226 \200\223236. Kuttner , L. ( 2010 ). A child in pain: what health professionals can do to help . Stevens , B. J. , Abbott , L. K. , Yamada , J. , Harrison , D. , Stinson , J. , Taddio , A. , et al . ( 2011 ). Epidemiology and management of painful procedures in children in Canad ian hospitals . CMAJ , 183 , E403 \200\223410. Bethel, CT : Crown House Publishing Ltd . LaMontagne , L. , Hepworth , J. T. , Salisbury , M. H. , and Cohen , F. ( 2003 a). Eff ects of coping instruction in reducing young adolescents \200\231 pain aft er major spinal surg ery . Orthopedic Nurs , 22 , 398 \200\223403. Stevenson , M. D. , Bivins , C. M. , O \200\231Brien , K. , and Gonzalez del Rey , J. A. ( 2005 ). Child life intervention during angiocatheter insertion in the pediatric emergency d epartment . Pediatr Emerg Care , 21 , 712 \200\223718. Suls , J. and Wan , C. K. ( 1989 ). Eff ects of sensory and procedural information on coping with stressful medical procedures and pain: a meta-analysis . J Consult Clin Psychol , 57 , 372 \200\223379. LaMontagne , L. L. , Hepworth , J. T. , Cohen , F. , and Salisbury , M. H. ( 2003 b). Cogni tive-behavioral intervention eff ects on adolescents \200\231 anxiety and pain following sp inal fusion surgery . Nurs Res , 52 , 183 \200\223190. 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McCue , K. and Hicks , M. ( 2007 ). From vision to reality: the expansion of the child life role . Child Life Council , 25 , 2 \200\2238. McGee , K. ( 2003 ). Th e role of a child life specialist in a pediatric radiology Uman , L. S. , Chambers , C. T. , McGrath , P. J. , and Kisely , S. ( 2006 ). Psychological interventions for needle-related procedural pain and distress in children and adolescents . Cochrane Database Syst Rev , 4 , CD005179 . department. Pediatr Radiol , 467 \200\223474. McMurtry , C. M. , Chambers , C. T. , McGrath , P. J. , and Asp , E. ( 2010 ). When \200 \230don \200\231t worry \200\231 communicates fear: children \200\231s perceptions of paren tal reassurance and distraction during a painful medical procedure . Pain , 150 , 52 \200 \22358. Visintainer , M. A. , and Wolfer , J. A. ( 1975 ). Psychological preparation for surgical p ediatric patients: the eff ect on children \200\231s and parent \200\231s stress responses and adjustment . Pediatrics , 56 , 187 \200\223202. McQueen , A. , Cress , C. , and Tothy , A. ( 2012 ). Using a tablet computer during pediatr ic procedures: A case series and review of the \200\230apps. \200\231 Pediatr Emerg Care , 7 , 712 \200\223714. Wojtasik , S. and White , C. ( 2009 ). Th e story of child life . In R.W. Th ompson , (ed.) Th e handbook of child life: a guide for pediatric psychosocial care , pp. 3 \200\22332. S pringfi eld, IL : Charles C. Th omas . Miller , K. , Rodger , S. , Bucolo , S. , Greer , R. , and Kimble , R. M. ( 2009 ). Multi- modal distraction. Using technology to combat pain in young children with burn injuries . B urns , 36 , 647 \200\223658. Young , K. D. ( 2005 ). Pediatric procedural pain . Ann Emerg Med , 45 , 160 \200\223171. Zempsky , W. T. , and Cravero , J. P. ( 2004 ). Clinical report: relief of pain and anxiety in pediatric patients in emergency medical systems . Pediatrics , 114 , 1348 \200\2231356 . Ostrenga , M. A. ( 1980 ). Guidelines for medical play . Evanson, IL : Hospital Play Equipment . Patterson , K. L. , and Ware , L. L. ( 1988 ). Coping skills for children undergoing painfu l medical procedures . Issues Compr Pediatr Nurs , 11 , 113 \200\223143. CHAPTER 53 Procedural pain distraction Lindsey L. Cohen , Laura A. Cousins, and Sarah R. Ma rtin Summary Th is chapter provides a brief overview of pediatric procedural pain, highlighting some of the negative repercussions of untreated pain. Th e behavioral approach of distracti on is covered in depth, starting with the theoretical underpinnings of this pain management intervention and then summarizing the distraction literature across children \200\231s pai n during immunizations, venous access, burn debride- ment and treatment, and cancer treatme nts. Th e chapter concludes with a discussion of some of the other reviews of this literatu re as well as clinical and research considerations when examining distraction for pediatric pain management. to infl uence long-term health care attitudes and behavior (Chen et al., 2000 ; Jones et al ., 2008 ; Kennedy et al., 2008 ; Pate et al., 1996 ; Taddio et al., 2009 ). On a physiologi cal level, early pain might alter the pain-processing neuronal circuitry leading to heighte ned pain perception in the future (e.g. Hermann et al., 2006 ; Ruda et al., 2000 ; Taddio e t al., 1997 ). Behavioral treatment of pediatric procedural pain Given the immediate and delayed negative eff ects of acute paediat- ric procedures, analgesics and sedatives have been used to provi de some pain relief; however, these approaches have failed to consist- ently eliminate pain and oft en do little to decrease fear or anxiety. In addition, pharmacological approaches are less frequently employed for venous access and immunization injections, likely due to t he brevity of the procedure. Fortunately, researchers and clinicians have employed behavior al approaches to minimize the negative physical and emotional aspects of routine invasive m edical proce- dures. Reviews of the literature suggest that \200\224generally speaking \200 \224 behavioral approaches are benefi cial to children facing distressing and painful medic al events (e.g. Pillai Riddell et al., 2011 ; Powers, 1999; Uman et al., 2010 ). Unpacking these reviews quickly reveals that the \200\230devil is in the details \200\231; there are many diff erent behavioral approaches used with a variety of acute medical procedures to h elp a diversity of children. Behavioral interventions range from fairly circumscribed appro aches (e.g. having children cough during venous access; Wallace et al., 2010 ) to multicomp onent packages (e.g. imagery, physical vibration stimulation, distraction; Berberich and La ndman, 2009 ); the acute pain literature spans experimen- tal analogous approaches (e.g. co ld-pressor; Dahlquist et al., 2007 ) to routine brief procedures (e.g. venous access; Cohen , 2008 ) to more invasive and severe medical events (e.g. burn debridement; Hoff man et al. , 2000 ); and patients are diverse in a number of important ways (e.g. age, gender, culture , temperament, prior expe- rience). In an attempt to provide some depth in this broad topic , this chapter will focus only on the use of distraction for a sample of children \200\231s acute invasive medical procedures. Other psychologi- cal interventions (e.g. cognitive beh avioral therapies (Logan et al., Chapter 50 ), operant based treatment (Slifer et al., Chap ter 51 ), bio- feedback (Stinson and Jibb, Chapter 55 )) and physical interventions Overview of pediatric procedural pain Starting at birth and continuing through development, children will undergo a host of routine as well as unplanned invasive medi- cal procedures . As an example, the World Health Organization (WHO) recommends approximately 20 to 30 vacc inations by 6 years of age (WHO, 2012 ). Additional vaccines for encephalitis, yellow fever , typhoid, cholera, meningococcal, rabies, mumps, and infl uenza are recommended for certai n geographic locations and high-risk populations (WHO, 2012 ). Th e majority of these vacci na- tions are administered via intramuscular injections. Beyond rou- tine procedures, rough ly 78% of children admitted to hospitals will undergo at least one medical procedure, typic ally involving needles (e.g. venous access; Stevens et al., 2011 ). Although immunizations, venous access, and other invasive medical events are critical for children \200\231s healt h, children fi nd needle procedures anxiety-provok- ing and painful (e.g. Jacobsen et al., 2001 ; Schechter et al., 2007 ). For example, data suggest that over half of children requi re physical restraint during routine immunizations (Blount et al., 1992 ). Although invasive events are a necessary aspect of appropriate health care, there can be a host of sequelae. First, the high pain intensity associated with routine and unplanned proc edures can contribute to immediate fear and anxiety, in turn heightening the pain experienc e in a cyclical fashion (McGrath, 1994 ; Rhudy and Meagher, 2003). Th e child \200\231s neg ative physical and aff ective reactions might lead to disruptive behavior (e.g. Bijttebier and Vertommen, 1998 ; Broome et al., 1990 ) and contribute to parents \200\231 anxiety (e.g . Kuppenheimer and Brown, 2002 ). Second, these nega- tive sensations and emotions associat ed with medical care are likely SECTION 7 psychosocial interventions 554 the degree to which two competing tasks utilize the same infor- mation-processing domain (W ickens, 1984 ). Researchers suggest that the level of pain perception results from how info rmation is processed according to the three domains, with detection of pain primarily occup ying the perceptual and spatial resources (Johnson et al., 1998 ). In contrast to LCT, MRT predicts that distraction is most eff ective if engaging the same system as pain (i.e. perc eptual). Th us, a distraction such as a vibrating device placed on the arm (e.g. Berberich and Landman, 2009 ; Baxter et al., 2011 ) is theorized to optimize interference with pain r elated to an injection in the same arm. (e.g. physical therapy (Tupper et al., Chapter 56 ), occupational ther- apy (Holsti et al., Chapter 57 )) are fully described in other chapters in this volume. Distraction for pediatric procedural pain Th eories of distraction mechanisms Distraction i s generally defi ned as shift ing attention from one source onto the new one, whether it be internal (e.g. imagery) or external (e.g. watching a movie). Within the fi eld of pediatri c procedural pain management, distraction has been described as redirecting a child \200 \231s attention away from anxiety-provoking painful medical stimuli, such as needles, to en gaging or enjoyable stimuli (Kleiber and McCarthy, 2006 ; Sander et al., 2002 ). Finally, attention can be operationalized and assessed behavior- ally, as visual or auditor y orienting responses to external stimuli (Pavlov, 1927 ). Mowrer \200\231s two-factor lear ning theory (Mowrer, 1947 ) asserts that both classical conditioning and instrumental condi tioning play a signifi cant role in pain responsitivity. In clas- sical conditioning, a neu tral stimulus, such as medical equipment, accompanies a pain-eliciting unconditioned stimul us (UCS), which consistently produces an unconditioned response (UCR) (e.g. pull- ing away) . Due to this association, the neutral stimulus becomes a conditioned stimulus (CS) that el icits a conditioned response (CR) of fear or anxiety preceding the UCS. In instrumental con dition- ing, avoidant responding (e.g. crying) follows the CR and persists through negative reinforcement, such as a decrease in fear, as a means of avoiding the CS and UCS. Cohen ( 2002 ) suggests that distraction tasks deter attention away from painful stimuli and con- d itioned stimuli that also evoke distress, ultimately reducing the CR and UCR that develop f rom painful pediatric procedures (i.e. a conditioned fear response). Distraction may also p roduce behav- iours incompatible with distress, such as relaxation or laughter. Despite the lack of a unifying theoretical framework for distraction mechanisms (DeMore and Cohen, 200 5 ), distraction remains one of the most prevalent forms of behavioral pain management amon g health care professionals. Th is is likely due to its ease of use. Physiologically, theorists propose that distraction or selective attention may enhance elec trical activity in the brain in response to a distraction task (i.e. the attended-to stimul us) as compared to the noxious or painful stimulus (i.e. the ignored stimuli). Several stud ies have shown that distraction tasks reduce the activity of brain areas known to process p ain stimuli (Bantick et al., 2002 ; Frankenstein et al., 2001 ; Petrovic et al., 2000 ). Ac cording to the gate control theory of pain (Melzack and Wall, 1965 ; Wall, 1978 ), the subs tantia gelatinosa serves as a gate control system by modulating ascending impulses from per ipheral nerves before they are perceived as pain by the cerebral cortex. When external (e.g . massage) and internal non-nociceptive input (e.g. anxiety) surpass nociceptive (pain) inp ut, the gate may partially or entirely shut, blocking the pain signal. A distraction interv ention is thus hypothesized to mitigate pain through descending non-nociceptive impulses th at inhibit the chief nociceptive signal, altering nociceptive responses (Melzack and Wall, 1965 ), although it remains unknown how specifi c char- acteristics of distraction stimuli may alter gate modulation. Attention can also be operationalized and assessed cognitively. A prominent cognitive theor y, limited attentional capacity theory (LCT; McCaul and Malott, 1984 ), relies on two assum ptions to sup- port the analgesic eff ect of distraction. Th e fi rst assumption defi nes n ociception as an intentional process that requires eff ort and atten- tional focus on the e liciting stimulus. Th e second assumption pos- its that attentional capacity is limited and nociceptive stimuli will not be perceived if an individual \200\231s attentional focus is completely diverted to a specifi c task. Since undivided attention is diffi cult to achieve , distraction is less eff ective with a noxious stimulus of greater intensity (e.g. burn de bridement) or with a distraction stimulus of lesser intensity (e.g. conversation on a topic that is not unique, such as school activities). LCT predicts that distrac- tion will be mo re eff ective than placebo and redefi nitional strate- gies (e.g. cognitive restructuring o f fear) at low levels of noxious stimulus intensity. Additionally, distraction will be more eff ective in managing mild levels of pain and distraction stimuli that require greater at tentional capacity will inhibit more attention needed to perceive pain (McCaul and Malott, 1984 ). Due to the theory \200\231s cir- cular assumptions and elementary reliance on one d omain of infor- mation processing, a more advanced theory, multiple attentional resource th eory (MRT; Wickens, 1984 , 2002 ) developed. E \203 cacy of distraction for pediatric procedural pain When reviewing the pediatric pain literature, it should be noted that there is great variability in what is described as dis traction in form, function, and effi cacy. For example, a cartoon shown to a child during a procedure might serve the intended purpose of inducing a positive-mood state incompatible with distress, engag- ing a child in mathematical computations might occupy attentional res ources, and a virtual-reality head-mounted display might eff ec- tively remove all medical stimuli from the visual and auditory fi elds. Th us, although all of these approaches can b e described as \200\230distrac- tion \200\231, they might be quite diff erent in topograph y and mechanism of eff ect. To further complicate the issues, individual characteristics of the child (e.g. age, temperament, coping style) might react with the distraction such that it assumes a diff erent function. For example, some children might fi nd the latest rap so ng to be an enjoyable dis- traction from the threatening sound of a dental drill, while oth ers might prefer the drill. Th e variability and subsequent eff ectiveness of distraction i s highlighted by the eff orts of Kleiber and col- leagues who have developed a scale that m easures both the quan- tity and quality of parent-provided distraction (Kleiber et al., 200 7 ; McCarthy et al., 2010a , 2010b ). Given all of these caveats about distraction for acut e pediatric procedural pain, it is not surprising that results in the pediatric pain litera ture are inconsistent (e.g. Carlson et al., 2000 ; Cramer-Berness, 2007 ). Acknowledging th at MRT proposes three distinct domains of information-processing capacity, including the perce ptual demands of a task, tasks requir- ing a spatially driven manual response or verbal res ponse, and tasks perceived visually versus aurally. According to this theory, the level of interference when processing other stimuli is dependent upon CHAPTER 53 procedural pain distraction 555 there is variability in the eff ects of distraction within and between studies, the subsequ ent sections will highlight the use of distrac- tion in diff erent common acute pediatric p rocedures. In addition, given the large number of pediatric procedural pain studies that in corporate distraction, this review will highlight some of the stud- ies that exemplify uniq ue aspects of the approach. To date, the immunization pain literature has predominantly focused on preschool-aged child ren due to the numerous vaccina- tions needed for school entry and their high level of repo rted dis- tress. Although a few studies support the use of distraction for infant (Cohen, 2 002 ; Cohen et al., 2006 ; Felt et al., 2000 ) and pre-adoles- cent participant samples (e. g. Cohen et al., 1999 ), further research tailored to these age groups is warranted (Cramer -Berness, 2007 ; Schechter et al., 2007 ). Additionally, most participant samples have cons isted of Caucasian mother \200\223child dyads, limiting the generaliz- ability of fi ndings to other races, ethnicities, and caregivers (DeMore and Cohen, 2005 ). Unfortunately, pare nts and health care profes- sionals still exhibit a poor understanding of the value in empl oying distraction for immunization pain relief (Chambers et al., 2009 ). Immunizations Immunization schedules vary by country, but it is generally recom- mended tha t children receive 20 to 30 vaccinations by 6 years of age (WHO, 2012 ). Th e majority of t hese vaccinations are administered via intramuscular injection, which children fi nd anxiet y-providing and painful (e.g. Jacobsen et al., 2001 ). As pediatric intramuscular immunizat ion injections remain the most common painful pae- diatric medical procedures in health car e settings, distraction has been evaluated in a number of studies (Schechter et al., 2007 ) . For example, a series of studies evaluating nurse-led movie distraction during immunizati ons demonstrated that distraction was gener- ally benefi cial to infants (Cohen, 2002 ; Coh en et al., 2006 ), pre- schoolers (Cohen et al., 1997 ), and preadolescents (Cohen et al., 1999 ). However, fi ndings were not consistent across all measures or all phases of the pro cedure. Wallace et al. ( 2010 ) evaluated the effi cacy of the \200\230cough trick, \200 \231 requiring 4- to 5-year-olds and 11- to 13-year-olds to provide several coughs prior to and coinciding with immunization injections. Th is technique is thought to distract childr en from the immunization by focusing on coughing when prompted and possibly creating antago nistic sensations developed from the noise and feeling of the cough. Of note, the cough tri ck was eff ective for Hispanic white or non-Hispanic white children ( t 33 = \210\2222.86, p <0.01), but did not prove benefi cial to non-Hispanic black children. 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.