Harrison , D. , Loughnan , P. , Manias , E. , Gordon , I. , and Johnston , L. ( 2009 ). Rep eated doses of sucrose in infants continue to reduce procedural pain during prolonged hospi talizations . Nursing Res , 58 , 427 \200\223434. Blass , E. and Ciaramitaro , V. ( 1994 ). A new look at some old mechanisms in human newborns . Monogr Soc Res Child Dev , 59 . Blass , E. , Fitzgerald , E. , and Kehoe , P. ( 1987 ). Interactions between sucrose, pain and isolation distress . Pharmacol Biochem Behav , 26 , 483 \200\223489. Blass , E. M. ( 1 997 ). Interactions between contact and chemosensory mechanisms in pain modulation in 10-da y-old rats . Behavioral Neurosci , 111 , 147 \200\223154. Harrison , D. , Stevens , B. , Bueno , M. , Yamada , J. , Adams-Webber , T. , Beyene , J. , et al . ( 2010 b). Effi cacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review . Arch Dis Child , 95 , 406 \200\223413. Harrison , D. , Yamada , J. , Adams-Webber , T. , Ohlsson , A. , Beyene , J. , and Stevens , B. ( 2011 ). Sweet tasting solutions for reduction of needle-related procedural pain in c hildren aged 1 to 16 years . Cochrane Database Syst Rev , 10 , CD008408 . Blass , E. M. , Fillion , T. J. , Rochat , P. , Hoff meyer , L. B. , Rochat , P. , and Metz ger , M. A. ( 1989 ). Sensorimotor and motivational determinants of hand-mouth coordination in 1 \200\2233-day-old human infants . Dev Psychol , 25 , 963 \200\223975. Blass , E. M. , and Fitzgerald , E. ( 1988 ). Milk-induced analgesia and comforting in 10-day-old rats: o pioid mediation . Pharmacol Biochem Behav , 29 , 9 \200\22313. Henderson-Smart , D. and Australian & New Zealand Neonatal Network. ( 2007 ). Evidence upta ke using networks \200\224Newborn Pain project . Sydney : National Institute of Clinical St udies, National Health & Medical Research Council . Blass , E. M. , and Hoff meyer , L. B. ( 1991 ). Sucrose as an analgesic for newborn infants . Pediatrics , 87 , 215 \200\223218. Johnston , C. , Barrington , K. J. , Taddio , A. , Carbajal , R. , and Filion , F. ( 2011 ) . Pain in Canadian NICUs: have we improved over the past 12 years? Clin J Pain , 27 , 225 \200\223232. Blass , E. M. , Jackson , A. M. , and Smotherman , W. P. ( 1991 ). Milk-induced, opioid-med iated antinociception in rats at the time of cesarean delivery . Behav Neurosci , 105 , 677 \200\223686. Johnston , C. C. , Filion , F. , Snider , L. , Limperopoulos , C. , Majnemer , A. , Pelausa , E. , et al . ( 2007 ). How much sucrose is too much sucrose? Pediatrics , 119 (1), 226 . Blass , E. M. , and Shah , A. ( 1995 ). Pain-reducing properties of sucrose in human newborns . Chem Senses , 20 , 29 \200\22335. Blass , E. M. , and Shide , D. J. ( 1994 ). Some comparisons among the calming and pain-rel ieving eff ects of sucrose, glucose, fructose and lactose in infant rats . Chem Senses , 19 , 239 \200\223249. Johnston , C. C. , Filion , F. , Snider , L. , Majnemer , A. , Limperopoulos , C. , Walker , C. D. , et al . ( 2002 ). Routine sucrose analgesia during the fi rst week of life in neo nates younger than 31 weeks \200\231 postconceptional age . Pediatrics , 110 , 523 \200 \223528. Blass , E. M. , and Smith , B. A. ( 1992 ). Diff erential eff ects of sucrose, fructose, gl ucose, and lactose on crying in 1- to 3-day-old human infants: qualitative and quantitative considerations . Dev Psychol , 28 , 804 \200\223810. Bueno , M. , Yamada , J. , Harrison , D. , Kahn , S. , Adams-Webber , T. , Beyene , J. , et al . (2013). A systematic review an d meta-analyzes of non-sucrose sweet solutions sucrose for pain relief in neonates. Pain Re s Manage , 18, 153 \200\223161. Lewkowski , M. D. , Barr , R. G. , Sherrard , A. , Lessard , J. , Harris , A. R. , and Youn g , S. N. ( 2003 ). Eff ects of chewing gum on responses to routine painful procedures in c hildren . Physiol Behav , 79 , 257 \200\223265. Losacco , V. , Cuttini , M. , Greisen , G. , Haumont , D. , Pallas-Alonso , C. R. , Pierrat , V. , et al . ( 2011 ). Heel blood sampling in European neonatal intensive care units: co mpliance with pain management guidelines . Arch Dis Child Fetal Neonatal Ed , 96 , F65 \200\22368. Carbajal , R. , Lenclen , R. , Jugie , M. , Paupe , A. , Barton , B. A. , and Anand , K. J. S. ( 2005 ). Morphine does not provide adequate analgesia for acute procedural pain among preterm neonates . Pediatrics , 115 , 1494 \200\2231500. McKay , L. D. , Kenney , N. J. , Edens , N. K. , Williams , R. H. , and Woods , S. C. ( 198 1 ). Intracerebroventricular beta-endorphin increases food intake of rats . Life Sci , 29 , 1429 \200\2231434. SECTION 6 pharmacological interventions 516 Smith , B. A. , and Blass , E. ( 1996 ). Taste-mediated calming in premature, Mennella , J. A. , Pepino , M. Y. , Lehmann-Castor , S. M. , and Yourshaw , L. M. ( 2010 ). Sweet preferences and analgesia during childhood:eff ects of family history of alcoholism and depression . Addiction , 105 , 666 \200\223675. Miller , A. , Barr , R. G. , and Young , S. N. ( 1994 ). Th e cold pressor test in children: methodological aspects and the analg esic eff ect of intraoral sucrose . Pain , 56 , 175 \200\223183. preterm, and full-term infants . Dev Psychol , 32 , 1084 \200\2231089. Smith , B. A. , Fillion , T. J. , and Blass , E. M. ( 1990 ). Orally mediated sources of ca lming in 1- to 3-day-old human infants . Dev Psychol , 26 , 731 \200\223737. Smith , B. A. , Stevens , K. , Torgerson , W. S. , and Kim , J. H. ( 1992 ). Diminished reactivity of po stmature human infants to sucrose compared with term infants . Dev Psychol , 28 , 811 \200 \223820. Mucignat , V. , Ducrocq , S. , Lebas , F. , Mochel , F. , Baudon , J. J. , and Gold , F. ( 2004 ). Analgesic eff ects of EMLA cream and saccharose solution for subcutaneous injection s in preterm newborns: a prospective study of 265 injections . Arch Pediatr , 11 , 921 \200\223925. Stevens , B. , Abbott , L. , Yamada , J. , Harrison , D. , Stinson , J. , Taddio , A. , et al . ( 2011 ). Epidemiology and management of painful procedures in hospitalized children a cross Canada . CMAJ , 183 , E403 \200\223E410. Norman , E. , Rosen , I. , Vanhatalo , S. , Stjernqvist , K. , Okland , O. , Fellman , V. , and Hellstrom-Westas , L. ( 2008 ). Electroencephalographic response to procedural pain in healthy term newborn infants . Pediatric Res , 64 , 429 \200\223434. Stevens , B. , Taddio , A. , Ohlsson , A. , and Einarson , T. ( 1997 ). Th e effi cacy of s ucrose for relieving procedural pain in neonates-a systematic review and meta-analysis . Ac ta P diatr , 86 , 837 \200\223842. Stevens , B. , Yamada , J. , Beyene , J. , Gibbins , S. , Petryshen , P. , Stinson , J. , a nd Narciso , J. ( 2005 ). Consistent management of repeated procedural pain with sucrose in preterm neonates: Is it eff ective and safe for repeated use over time? Clin J Pain , 21 , 543 \200\223548. Pepino , M. Y. , and Mennella , J. A. ( 2005 ). Sucrose-induced analgesia is related to swe et preferences in children but not adults . Pain , 119 , 210 \200\223218. Poulsen , M. ( 2 009 ). Cane sugar unsuitable for use as analgesic in pediatric vaccination . Sygeplejersken/Dan J Nurs , 106 , 54 \200\22357. Stevens , B. , Yamada , J. , and Ohlsson , A. ( 2010 ). Sucrose for analgesia in newborn in fants undergoing painful procedures . Cochrane Database Syst Rev , 1 , CD001069 . Ramenghi , L. A. , Evans , D. J. , and Levene , M. I. ( 1999 ). \200\230Sucrose analgesia \200\231: absorptive mechanism or taste perception? Arch Dis Child Fetal Neonatal Ed , 80 , F146 \200\2231467. Stevens , B. , Yamada , J. , and Ohlsson , A. ( 2013 ). Sucrose for analgesia in newborn in fants undergoing painful procedures . Cochrane Database Syst Rev , 1 , CD001069 . Ren , K. , Blass , E. M. , Zhou , Q. , and Dubner , R. ( 1997 ). Suckling and sucrose inges tion suppress persistent hyperalgesia and spinal Fos expression aft er forepaw infl ammatio n in infant rats . Proc Natl Acad Sci U S A , 94 , 1471 \200\2231475. Rogers , A. J. , Gre enwald , M. H. , Deguzman , M. A. , Kelley , M. E. , and Simon , H. K. ( 2006 ). A randomiz ed, controlled trial of sucrose analgesia in infants younger than 90 days of age who requir e bladder catheterization in the pediatric emergency department . Acad Emerg Med , 13 , 617 \200\223622. Royal Australasian College of Physicians. ( 2005 ). Guideline statement: man agement of procedure-related pain in neonates . Sydney : Pediatrics & Child Health Division , Th e Royal Australasian College of Physicians . Shide , D. J. , and Blass , E. M. ( 1989 ). Opioidlike eff ects of intraoral infusions of corn oil and polycose on stress reactions in 10-day-old rats . Behav Neurosci , 103 , 1168 \200\2231175. Taddio , A. , Chambers , C. T. , Halperin , S. A. , Ipp , M. , Lockett , D. , Rieder , M. J . , and Shah , V. ( 2009 ). Inadequate pain management during routine childhood immunizatio ns: the nerve of it . Clin Th er , 31 (Suppl 2), S152 \200\223167. Taddio , A. , Shah , V. , Shah , P. , and Katz , J. ( 2003 ). Beta-endorphin concentration aft er administration of sucrose in preterm infants . Arch Pediatr Adolesc Med , 157 , 1071 \200\2231074. Travers , S. ( 1993 ). Orosensory processing in neural systems of the nucleus of the solita ry tract . In S. Simon , and S. Roper (eds) Mechanisms of taste transduction , pp. 339 \200\223394. Boca Raton, FL : CRC Press . Tsao , J. C. I. , Evans , S. , Meldrum , M. , Altman , T. , and Zeltzer , L. K. ( 2007 ). A review of CAM for procedural pain in infancy: part I. sucrose and non-nutritive sucking . Evid Based Complement Alternat Med , 371 \200\223381. Slater , R. , Cornelissen , L. , Fabrizi , L. , Patten , D. , Yoxen , J. , Worley , A. , et al . ( 2010 ). Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomized controlled trial . Lancet , 376 (9748), 1225 \200\2231232. SECTION 7 Psychosocial interventions This page intentionally left blank CHAPTER 50 Cognitive-behavioral interventions Deirdre E. Logan , Rachael M. Coakley, and Br ittany N. Barber Garcia Cognitive-behavioral therapy (CBT) is the most commonly researched and empirically supporte d psychological treatment for the management of pediatric pain. CBT is a brief, goal-orient ed psychotherapy treatment using a hands-on, practical problem- solving approach (Kendall, 2012 ). It is based on the concept that thoughts, feelings, and behaviors are causally inte rrelated. Th is chapter off ers an overview of CBT and its application to pain management, describes specifi c cognitive-behavioral strategies commonly used for pediatric acute and c hronic pain problems, presents the empirical evidence supporting these approaches, and high lights key considerations and emerging directions in the use of CBT and related treatments for pediatric pain. Cognitive-behav- ioural theory highly instructive in nature, oft en incorporating the use of manuals and workbooks in sess ion, and homework assignments to solidify skills. Within a CBT framework, the therapist and patient work col- laboratively to identify problems and design learning experiences that w ill help to modify negative cognitions and dysfunctional behavioral patterns (Kendall, 2012 ). In practice today, CBT is an amalgam of cognitive and behavioral approaches that can be app lied in various combinations. Cognitive interventions include the use of skills such as ref raming, cognitive distraction, and positive self-talk statements. Behavioral strategies inc lude skills such as relaxation, exposure and desensitization, and modeling. Overarching ele ments of CBT include education, goal- setting (establishing desired outcomes and incorporat ing incen- tives to help achieve these outcomes), self-monitoring (increasing awareness of symptoms and responses through tracking in a diary- like fashion), and problem-solving (ide ntifying obstacles to one \200\231s goals and working collaboratively with the therapist to overcome these obstacles). Importantly, a CBT model also attends to the rela- tionship of cognition and behavior in the context of a child \200\231s envi- ronment (Kendall, 2012 ). Cognitive-behavioral theory Cognitive-behavioral theory, which underlies CBT, represents a convergence of two psychological theories; cognitive theory (Beck, 1979 ), which focuses on mental interpretations of experiences, and behavioral learning theory (Th orndike, 1913 ), which empha- sizes the shaping of behaviors through reinforcement. Cognitive- behavioral t heory merges these concepts into a model of treatment that targets cognitive appraisals and their infl uence on emotional and behavioral responses. In practice, CBT relies heavily on the modifi cation of thoughts and behaviors using the principles of reinforcement (Turk an d Rudy, 1989 ; see Slifer et al., Chapter 51, this volume). CBT for pain Th e use of CBT for pain problems is based on the understanding that pain is a complex biopsychosocial experience shaped not only by underlying pathophysiology but also by individuals \200\231 thoughts, feelings, and behaviors (e.g. Keefe and Gil, 1986 ). With in a CBT framework for pediatric pain, children are taught cognitive strate- gies to identi fy and restructure illogical or maladaptive thoughts related to pain. Children are also tau ght behavioral strategies to relieve physiological discomfort and relearn adaptive function ing patterns. CBT for pain specifi cally targets the common distorted thought that pain can not be controlled (Rogers, 2008 ). Treatment focuses on modifying this negative belief, enh ancing ability to solve pain-related problems, and providing a set of skills for managing p ain in an adaptive way. Goals of CBT for pain include gaining a sense of control over pain, reducing fear of pain, enhancing func- tion, increasing feelings of hopefulness and resour cefulness, and improving mood. CBT in practice CBT fi rst emerged in the early 1970s and quickly gained recog- nition due to both its eff ectiveness for a wide array of mood and behavioral disturbances and its tim e-limited model of care. Th ere are many components of CBT that distinguish it from other t ypes of psychotherapy. CBT is usually provided by psychologists, though some skilled licens ed social workers and masters-level counselors also practice CBT. CBT is present-focused an d time-limited. It is typically delivered individually in weekly therapy sessions, though i t can also be eff ectively administered in a group format (Barakat et al., 2007 ; Hayutin e t al., 2009 ; Logan and Simons, 2010 ). CBT is SECTION 7 psychosocial interventions 520 Table 50.1 CBT techniques and their typical uses Within the literature on pediatric pain, CBT interventions have demonstrated promising impr ovements in self-effi cacy, self-man- agement, family functioning, psychosocial well-being, pain sever- ity, school attendance, and feelings of hopefulness (Barlow and Ellard, 2004 ) . Although the literature has not yet clearly identifi ed which constellation of cognitive or behavioral interventions are most eff ective for specifi c groups based on characteristi cs such as age, gender, or type of pain, there is strong evidence that taken as a whole, th ese strategies are highly eff ective for treatment of acute and chronic pain for children a s well as adults (Eccleston et al., 2002 ; Turk et al., 2008 ). CBT technique Used for procedural pain? Used for chronic pain? Cognitive reframing (cid:57) (cid:57) Desensitization (cid:57) (cid:57) Distraction (cid:57) (cid:57) Modeling (cid:57) Multicomponent packages (cid:57) (cid:57) Positive self- statements (aka coping statements) (cid:57) (cid:57) CBT for pain management typically focuses initially on the pro- vision of developmentally t argeted education about a child \200\231s con- dition (Rogers, 2008 ), but most importantly on the relationship between thoughts, physiological changes in the body, and behav- iours or actions. For example, a child with a chronic pain condition such as complex regional pai n syndrome would be taught that she would not cause harm to herself by using her aff ected limb. A child preparing for a painful procedure would be taught that pain sensa- tions are diminished when attention is allocated away from painful stimuli. Treatment addresses the n egative or fearful thoughts (e.g. \200\230it \200\231s going to hurt too much \200\231, \200\230I can \200\231t do this \200\231) that produce physi- ological changes (e.g. racing heart, shortness of breath, increased discomfort) and resultant behavioral changes (e.g. p oor adher- ence, withdrawal from activity). CBT also directly addresses mala- daptive behav ioral responses with the use of strategies such as graded exposure to anxiety producing sti muli and reinforcement for adaptive behaviors. Preparation (cid:57) Psychoeducation (cid:57) Rehearsal (cid:57) Relaxation (cid:57) (cid:57) that detailed preparation prior to a medical procedure may reduce anxiety in some children but may create more anticipatory atten- tion to the procedure than is helpful for others. B oth developmental level and individual child coping style may infl uence utility of these t echniques. Psychoeducation for chronic pain For chronic pain, psychoeducation entails providing the ch ild and family with a clear explanation of what chronic pain is (e.g. the non- protective n ature of chronic pain), how pain signals are transmitted in the body, the role of the brain in processing pain information, and an explanation of the biopsychosocial model of pain (s ee Pillai Riddell et al., Chapter 9, this volume) and the transactional rela- tionship betw een stress and pain. Psychoeducation should include a rationale for how and why cognitive-b ehavioral strategies can eff ectively reduce pain and restore function. It is helpful to in corpo- rate written educational materials so that children and families can refer back to t hem as needed. Speci \201 c CBT techniques for pediatric pain Many cognitive-behavioral techniques are us eful both in the acute context of procedural pain (e.g. injections, blood draws, laceration repairs) and for chronic pain conditions (e.g. headache, abdominal pain, disease-related p ain, musculoskeletal pain). Each technique reviewed here (see Table 50.1 ) aims to achieve one or more of the following CBT goals: (1) to direct the child \200\231s attention away fr om pain, (2) to enhance the child \200\231s sense of control over pain, and (3) to diminish negative thoughts and feelings related to pain. Although operant strategies (i.e. providin g reinforcement or incentives for coping adaptively with pain) are sometimes included withi n the scope of cognitive-behavioral pain management, those strategies are detailed elsewher e by Slifer et al. (Chapter 51, this volume). Evidence base for preparation and psychoeducation A few randomized controlled trials (RCTs) have examined the eff ects of preparation on children \200\231s response to procedure pain (Harrison, 1991 ; Tak and van Bon, 2006 ). A meta-analysis of this evidence shows positive eff ects of preparation on observer reports of pain during needle procedures but insuffi c ient evidence of eff ects on self-report of pain or behavioral measures of distress (Uman e t al., 2008 ). Results from one early study (Dahlquist et al., 1985 ) suggest that individu al factors such as the quality (but not quantity) of a child \200\231s previous medical exp erience can aff ect whether prepara- tion helps the child to cope more adaptively with proc edural pain, but more research is needed in this area. Preparation and psychoeducation Education is a fundamental component of all CBT interventio ns. Educational interventions provide a rationale for how and why other cognitive-behaviora l strategies can eff ectively reduce pain and distress. Preparation for procedural pain Preparation is a specifi c educational intervention that en tails explaining to the child in advance exactly what the procedure will involve. Typically this includes breaking down the procedure into detailed steps to reduce anxiety and uncert ainty. Incorporating sen- sory information is useful (e.g. \200\230Th e nurse will tie a r ubber band around your arm; this will feel tight \200\231). Preparation can include showing the child where the procedure will occur and specifi c equipment that will be used. Th ere are also child-friendly proce- dure preparation kits available for purchase. It is importa nt to note Psychoeducation for pediatric chronic pain is rarely delivered as a stand-alone interventio n; thus, there is little literature examin- ing its eff ectiveness in isolation. One RCT of adult chronic pain patients (Moseley et al., 2004 ) showed that education about pain neuro physiology resulted in changes in pain cognitions and physi- cal task performance, although the education intervention did not result in changes in reported disability. CHAPTER 50 cognitive-behavioral interventions 521 Distraction Th e primary goal of distraction is to shift the child \200\231s attention away from pain toward more enjoyable, engaging stimuli. Recent theories, backed by empirical su pport, hold that distraction can exert a power- ful analgesic eff ect that alters the activ ity on pain processing pathways in the brain (Bantick et al., 2002 ). Distraction is addres sed by Cohen et al. (Chapter 53, this volume). It is briefl y discussed here due to its cen tral role in CBT package treatments. Distraction can include both behaviourally oriented st rategies such as blowing bubbles or playing a videogame, and cognitively oriented strategie s such as non-procedure focused conversation or tasks (e.g. discussing a favorite movie or counting objects). Reading stories or watching videos are also eff ec- tive distractions fo r many children. Recently, virtual reality (VR) tech- nology has been employed to create in teractive and highly engaging distractions from pain (Lange et al., 2006 ; Mahrer and Gold, 2009 ). used for such purposes, or this can be done with a clinician (e.g. child life specialist) o r through coaching a parent to demonstrate appropriate coping techniques. Oft en, children benefi t most from education strategies that require them to assume a more active role. Th erefore, rehearsal, in which the child him/herself acts out the procedure, such as through medical play, can reduce anxiety and foster positive coping. Oft en, assuming the role of t he doctor or nurse and performing the procedure on a stuff ed animal or parent helps childr en acquire a sense of mastery of an anxiety-provoking situation that may otherwise feel unc ontrollable. In general, studies support preparation and modeling/rehearsal strategies as eff ective too ls for reducing anxiety and distress about medical procedures (Harbeck-Weber and McKee, 199 5 ) with some indication that they may help reduce pain as well. Only one small RCT specifi cally focused on modeling was reported in a meta- analysis (Zabin, 1982 ), cited in Uman e t al. ( 2008 ), and its results were not found to provide suffi cient evidence of benefi ts from this technique alone. Distraction for procedural pain Distraction is perhaps the most commonly employed cognitive - behavioral technique for coping with procedural pain. It is eas- ily employed in this set ting and can work well across a variety of ages and temperaments. Distraction techniques ar e generally not time intensive, require little advance preparation, and can be imple- mente d by a variety of clinicians. Parents can also be recruited to employ these strategies. Dis traction for chronic pain Distraction works similarly in chronic pain, but the chronicity o f the pain requires distractions that remain eff ective over time. Children and adolescents can identify activities that they enjoy and fi nd absorbing and can be encouraged to use t hose activities in attempts to cope with pain. Distractions may be social or solitary. Scho ol can also be framed as an adaptive distraction from pain, since children are more likely able to distract themselves from pain in school than when home in bed, for example. It is i mportant to work with the individual child to identify the distractions that work best. Cognitive reframing/positive self-statements Cognitive reframing refers to modifying one \200\231s thoughts about a dis- tressing situation so that they are less focused on negativ e aspects of the situation. Typically, children are taught fi rst to identify their negativ e thoughts or \200\230self-talk \200\231 about pain, then to challenge these thoughts, for example, by listing out evidence in support of the thought and evidence against it, and fi nally to modify these thoughts to produce less negative emotional responses. A related tec hnique, positive self-statements, focuses on developing a set of statements that emphasize one \200\231s ability to cope positively with a challenging situation. Statements should be brief, such as \200\230I can do it ! \200\231 or \200\230Th is will be over soon ! \200\231 Cognitive reframing and positive self-statements in procedural pain A child facing a painfu l procedure might say, \200\230I don \200\231t want to do this, it will hurt too much ! \200\231. Reframing this statement might entail highlighting how quickly the procedure will be over and reminding the child that s/he has strategies for coping with pain, so that the statement can be reframed as, \200\230Th is might be uncomfortable, but it will be over s oon and I can listen to my favorite song so I don \200\231t notice it as much \200\231. Cog nitive reframing can take place prior to, dur- ing, and aft er a painful procedure. Using c ognitive reframing aft er a procedure, sometimes referred to as memory alteration, is aimed at reducing the negative memories of a painful experience so they are not as distressing a nd do not predispose the child toward greater anxiety in subsequent painful procedures (Che n et al., 1999 ). Evidence base for distraction Among all the specifi c cognitive behavioral tools for managi ng procedural pain, distraction has the largest base of empirical sup- port (Cohen et al., 1997 ; Kleiber and Harper, 1999 ) Several sys- tematic and critical reviews (Chambers et al ., 2009 ; DeMore and Cohen, 2005 ; Powers, 1999 ; Uman et al., 2008 ) show large eff ect si zes for distraction as an intervention for pediatric procedural pain, with several recent s tudies specifi cally supporting VR-based distraction approaches in comparison to other dist raction tech- niques (Mahrer and Gold, 2009 ). For further information see Cohen et al. (Ch apter 53, this volume). Modeling and rehearsal Modeling and rehearsal techniques are aimed at reducing anticipa- to ry anxiety by helping the child to develop more realistic expecta- tions of a potentially p ainful situation and increasing comfort and familiarity with the situation. Th ey are there fore most well-suited to the procedural pain context. Cognitive reframing and positive self-statements in chronic pain A child with chronic pain might say, \200\230Th is pain is never going to get better \200\231. Th is negative thinki ng, referred to as \200\230catastrophizing \200\231, is commonly associated with chronic p ain (Sullivan et al., 2001 ; Turner and Aaron, 2001 ) Th e fi rst step in reframing negativ e or catastrophic thinking is to help a child gain awareness of his/her negative thinking p atterns using questionnaire assessments or thought monitoring procedures. Once recurrent ne gative thoughts are identifi ed, the therapist and child examine evidence supporting the th ought (e.g. \200\230I \200\231ve seen a lot of doctors but haven \200\231t gotten better Modeling and rehearsal for procedural pain For young children who are anxious about anticip ated painful procedures, it is oft en helpful to provide a demonstration (i.e. mod- elling) of an adult or another child underdoing the procedure and using positive coping strategies . Videotaped demonstrations can be SECTION 7 psychosocial interventions 522 Evidence base for exposure/desensitization A recent systematic review of exposure and desen sitization treat- ments for adults with chronic pain (Bailey et al., 2010 ) included sev- e ral RCTs (Leeuw et al., 2008 ; Woods and Asmundson, 2008 ) as well as many single case desi gn studies. Current evidence suggests that graded in vivo exposure eff ectively reduces pai n and fear-avoidance beliefs and behaviors. Few trials have examined exposure-based treatme nts in pediatric pain, but this is an emerging area of inquiry given the role of exposure i n newer treatment approaches such as acceptance and commitment therapy (ACT). Wicksell and col- leagues ( 2009 ) conducted a RCT of a ten-session ACT-based treat- ment with exposure as the primary intervention. Th e intervention led to greater reductions in pain, disabilit y, pain-related discomfort, and fear of pain compared to standard multidisciplinary treatme nt (including medication) for children with chronic pain. yet \200\231) and evidence against the thought (e.g. \200\230there are treatments availabl e that help with this kind of pain \200\231). If the evidence fails to fully support the ne gative thought, the child is taught to reframe this thought into a new, more adaptive thoug ht such as \200\230Th is pain has been with me for a long time, but now I \200\231m workin g on ways to feel better \200\231. Positive self-statements (e.g. \200\230I know I can do this ! \200\231, \200\230My pain WILL get better \200\231) can be used to foster adaptive coping and help challenge negative thought patterns. Evidence base for cognitive reframing Th ere are few published studies of interventions tha t test cognitive reframing or positive self-statement approaches in isolation; typi- cally they are incorporated into multicomponent CBT packages. One study (Chen et al., 1999 ) of m emory alteration following lum- bar puncture found that the group of children who participa ted in the memory alteration intervention reported less distress and pain than a control gr oup, both immediately aft er the procedure and at follow-up. However, this small study has not been replicated, so results should be interpreted cautiously. Th e overall pattern of f i nd- ings did not meet criteria to be considered effi cacious in a meta- analysis (Uman et al., 2008 ). Relaxation techniques: breathing, guided imagery, muscle relaxation Relaxation strategies f ocus on acquiring specifi c skills that can be used to decrease pain perception by promotin g a general sense of physical and psychological well-being. Th is relaxed state is incon- g ruent with intense pain perceptions. Relaxation approaches include deep (diaphragmatic) bre athing, progressive muscle relaxa- tion (PMR), and guided imagery techniques. Hypnosis also relies heavily on relaxation. See Liossi et al. (Chapter 54, this volume) for detailed exp lanations of these specifi c techniques. Exposure and psychological desensitization Exposure and psychological desensitization techn iques, widely used in CBT for anxiety problems, involve gradually increasing exposure to a feared stimulus over time while minimizing associated anxi- ety. Th e roots of this approac h lie in classical conditioning theory, which holds that the association between the stimul us (e.g. needle) and the response (fear, anxiety) is conditioned (learned) and can be progr essively weakened. Typically, systematic desensitization entails developing a hierarchy of anxiety-provoking situations ordered from least- to most-feared. Th rough a process called graded in vivo exposure, the child is then exposed to the fearful situations begin- ning wi th those identifi ed as least feared and gradually working up the hierarchy. Th e goal is t o encounter the situations safely, without the previously experienced distress, to unlink t hem from associated anxiety. Th e clinician may teach the child to engage in positive cop- ing strategies (e.g. relaxation) during this desensitization process. Relaxation techniques in procedural pain In the brief context of procedural pain experience s, deep breathing is perhaps the most commonly used relaxation tool. Oft en props such as b ubbles or party blowers are employed, particularly with younger children; these tools incor porate a component of distrac- tion that can augment the benefi ts of deep breathing. Recor ded instructions for progressive muscle relaxation and guided imagery procedures are availa ble and can be used in procedural settings when there is less preparation time available. Relaxation techniques for chronic pain Relaxation is widely used in chronic pain (e.g. Pale rmo et al., 2010 ). Learning to employ relaxation strategies in a self-directed manner prov ides children a greater sense of control over their physiologi- cal processes, which may he lp counteract feelings of helplessness induced by chronic pain. Sometimes these techniques are taught using computer-based biofeedback (see Zeltzer, Chapter 60, this volume), providi ng concrete visual and/or audio feedback to help the child gain increased awareness over pr eviously involuntary physiological processes. Many therapists provide children with audio-r ecordings to practice techniques between sessions. Desensitization in procedural pain Desensitization is a time-intensive strategy that requir es a number of sessions with a trained clinician prior to the procedure. Th erefore, in the procedural pain context it is typically used with children who are known to have high leve ls of pain-related anxiety in response to medical procedures such as injections. Prior to a procedure, children can work with a CBT therapist to develop and undergo a systematic proc ess of pairing successive exposures to the feared stimulus (e.g. needle) with relaxation an d use of other adaptive coping skills. Over time, the previously feared situation (e.g. the needle stick) ceases to produce signifi cant pain-related anxiety. In addition to using guided imagery to develop relaxing images, this technique can also foc us on pain-reducing imagery. For example, a child might be guided to imagine the \200\230p ain control center \200\231 in the brain and then locate specifi c controls that can help t o turn down pain mes- sages traveling to a specifi c body area. Th ese techniques are typic ally more eff ective when the child has been guided into a general state of relaxation prio r to engaging in imagery exercises (Kuttner, 1991 ). Desensitization in chronic pain Expectancy eff ects have a strong infl uence on pain percep tion (e.g. Logan and Rose, 2005 ). Many children with chronic pain develop a pattern of avo iding activities they believe will trigger or increase pain (Martin et al., 2007 ). Desensi tization can be used to reduce this pain-avoidance pattern, unlink the association between activi- ties and fear of pain, and help children to re-engage in activities, which can in t urn help to reduce pain. Evidence base for relaxation strategies Relaxation strategies have a good base of evidence supporting their use with pediatric patients in procedural pain contexts (Dahlquist, CHAPTER 50 cognitive-behavioral interventions 523 et al., 1985 ; French et al., 1994 ). Breathing exercises have been shown to be eff ective in reducing children \200\231s self-reported pain, observer rated distress, and nurse repor ted distress during routine immunization procedures (Chambers et al., 2009 ). In a meta-ana ly- sis published in 2010, Palermo and colleagues (Palermo et al., 2010 ) concluded that re laxation as a stand-alone cognitive-behavioral treatment was eff ective in reducing pain ac ross studies of children and adolescents with a variety of chronic pain conditions includin g headache, abdominal pain, and fi bromyalgia. Typically, however, these strategies along w ith most others described earlier, are incor- porated into multicomponent CBT packages. biofeedback engaging and benefi t from the concrete, visual aspects of this technique. In f act, studies have shown that children with headaches derive greater benefi t from biofeedba ck compared to adults (Sarafi no and Goehring, 2000 ). Evidence base for biofeedback Th e most established evidence exists for the use of thermal bio- feedback to treat migraine headache and for surface EMG bio- feedback in the treatment of tension-type headaches (Herman and Blanchard, 2002 ). Several studies have demonstrated support for combining biofeedback training with interventions targeting parental responses to pain (Allen and Shriver, 1998 ; Kroner-Herwig et al., 1998), with results suggesting th at this combined approach yields modestly better long-term outcomes than biofeedback treat- ment alone. In a meta-analytic review, Hermann et al. (1995) found evidence showing greate r eff ectiveness of biofeedback compared to placebo or prophylactic drugs for the treatment of headache. Biofeedback/biofeedback-assisted relaxation training Biofeedback is a therapeutic procedure that measures and \200\230feeds back \200\231 information about an individual \200\231s p hysiological activity (typi- cally indicators of autonomic arousal) to increase awareness o f and voluntary control over those physiological processes (Arena and Blanchard, 1996 ; Ols on and Schwartz, 2003 ). In the treatment of pediatric pain, biofeedback is oft en taught i n conjunction with other relaxation strategies. As biofeedback is only one component of thi s approach, it is oft en referred to as biofeedback-assisted relax- ation therapy. Because of the need for trained practitioners (most oft en psychologists), specialized equipment, a nd the need for prac- tice to become skilled with these techniques, biofeedback is most com monly used for chronic and recurrent pain conditions. Studies have also begun to demonstrate the effi cacy of bio- feedback with pediatric patien ts with chronic abdominal pain (Schurman et al., 2010 ; Weidert et al., 2003 ). Several stu dies pro- vide support for the use of biofeedback in the treatment of fi bro- myalgia sympt oms (Buckelew et al., 1998 ; van Santen et al., 2002 ), although none of these studies is s pecifi c to the pediatric popu- lation. In their recent meta-analysis of psychological ther apies for pediatric chronic pain, Palermo and colleagues ( 2010 ) concluded that biofeedbac k was eff ective in reducing pain, with an odds ratio of 23.34. However, additional well-de signed studies of specifi c bio- feedback modalities and biofeedback assisted relaxation ap proaches are needed, particularly studies that examine pain conditions other than headache and that include outcomes beyond pain reduction, such as improvements in physical and psych ological functioning. Additionally, research is needed to compare biofeedback train- ing to placebo conditions to elucidate its specifi c and non-specifi c eff ects. Th is is an impo rtant design consideration given the poten- tial infl uence of the novelty of this treatmen t approach. Patients and families may have a negative bias towards psychological therapy fo r chronic pain, but may have a positive bias towards expectations for improvement when rela xation or pain management is taught via biofeedback. Teasing apart whether biofeedback-assi sted relaxation is more benefi cial for chronic pain management as compared to relaxation t aught without biofeedback is an ongoing eff ort in the study of psychological interventions for chronic pain.