Distraction

Distraction involves a purposeful refocusing of attention from the threatening, anxiety-provoking aspects of a situation to less threatening thoughts, objects, sights, or sounds. Theoretically, the more attention demanded by the distractor, the less at-tentional capacity is available for processing the distressing or painful stimuli. Distraction techniques are adapted according to the age and developmental level. Rocking, patting, a pacifier, or a toy with lights and sounds can help distract an infant. Toddlers respond well to blowing bubbles, party blowers, and interactive books. With older children and adolescents, distraction techniques include listening to music, playing video games, working on riddles, or watching movies or television shows during the procedure.

Distraction as a coping technique has been shown to be helpful in reducing pain and distress during medical procedures (e.g., Cohen et al. 1999; Manimala et al. 2000; Stinson et al. 2008). In a meta-analysis of psychological interventions for needle-related procedural distress in children and adolescents, distraction was found to be one of the three most efficacious coping techniques utilized to help with painful medical interventions (Uman et al. 2006).

Treatment studies have experimentally manipulated distraction and compared it with other variables thought to help during medical procedures. Through these comparisons, the use of distraction has even been found to be more effective than traditional methods of managing procedure-related pain and distress. For example, in a study with school-age children, Cohen et al. (1999) examined differential responses to a series of three immunizations utilizing a Latin square design in which all participating children were exposed to each of the three experimental conditions (i.e., typical care, distraction, and eutectic mixture of lidocaine and prilocaine [EMLA] topical anesthetic). Distraction resulted in less child distress than either typical care or EMLA.

Another study compared the effects of distraction and parental reassurance on child distress and coping during immunizations (Manimala et al. 2000). Eighty-two children (ages 3-5 years) and their parents were alternately assigned to the parental reassurance group, the parental distraction group, or a control group. Parents in the reassurance group were taught that reassuring comments can comfort the child and reduce the child's fear, anxiety, and distress. Parents were instructed on how to use reassurance and encouraged to use this method during their child's immunization. Parents in the distraction group were informed that their child would be more fearful and distressed if he or she focused on the impending injection and were thus encouraged to engage their child in distracting activities (e.g., puzzles, coloring, toys, reading, and discussing nonmedical topics). Parents were also instructed to teach and encourage their children to use a party blower prior to and during the injection. Results indicated that children in the distraction group displayed the least amount of distress on several indexes. Moreover, children in the reassurance group displayed more verbal fear and needed to be restrained more often than children in either the distraction group or the control group. One explanation for the deleterious effects of reassurance is that rather than working to comfort the child, it may focus the child's attention on the fearful and painful aspects of the situation.

Coaching

Because children seldom spontaneously engage in coping behaviors, repeated prompting by adults is often necessary. In a study examining the effectiveness of nurse coaching and distraction on young children undergoing immunizations, Cohen et al. (1997) alternatively assigned children (ages 4-6 years) and parents to one of three groups: 1) standard care; 2) nurse coaching and cartoon distraction with no behavioral rehearsal; or 3) nurse coaching, cartoon distraction, and behavioral rehearsal. The two interventions were found to be superior and equally effective compared with standard care in terms of reducing child, parent, and nurse reports of distress as well as enhancing coping.

To determine if trained coaches are necessary for helping children cope with medical procedures, Cohen et al. (2002) conducted a study with 61 children (ages 3-7 years) undergoing routine immunizations. Children were alternately assigned to either a coping skills or a control group. Children in the coping skills group watched a video of a same-aged model engaging in "snake breathing" and positive self-statements throughout the immunization. After the video, the child was given time to practice the two skills with a trained research assistant. Children in the control group also watched a video on immunizations but were not given any specific suggestions on how to best cope. Parents in both groups did not watch the videos with their child.

Interestingly, although just before the procedure children in the coping skills group demonstrated that they had learned the requisite skills, the training did not lead to increased coping or decreased distress during the procedure. The authors suggested that this study offers evidence that training children in coping skills without the inclusion of adult coaches may be insufficient, especially for young children. However, as suggested earlier, parents who exhibit a high level of observable anxiety during their children's medical intervention often increase, rather than decrease, distress in their children (Frank et al. 1995). Thus, although most children will greatly benefit from having their parents trained as coaches, it is likely that parents with high anxiety will serve to interfere with effectiveness of coaching interventions.

Active Versus Passive Distraction

Researchers have argued that active distraction (e.g., playing with a toy or video game) that engages the child in manipulating objects or problem solving is more effective than passive distraction (e.g., watching a movie) because it utilizes more atten-tional resources (e.g., Dahlquist 1999). To this end, several studies have compared active and passive distraction to determine whether they are differentially effective in helping children cope with medical procedures. Dahlquist et al. (2007) examined the effectiveness of interactive versus passive distraction with 40 children (ages 5-13 years) undergoing cold pressor trials (i.e., immersion of the child's hand in cold water). Children in this study were randomly assigned to one of three groups: 1) interactive distraction; 2) passive distraction; or 3) no distraction control condition.

All children went through a baseline cold pressor trial in which pain tolerance and pain threshold were measured. During the second trial, children in the interactive group played a video game that used a joystick and virtual reality head-mounted display helmet. Children in the passive group wore the same helmet, but rather than playing the video game, they watched prerecorded footage of another child playing. To compare the relative benefits of interactive versus passive distraction in a within-subjects design, each child participated in one or two cold pressor trials. The experimental participants received a third trial of the distraction intervention they had not received in the second trial. Control participants all received a third and fourth trial utilizing each of the experimental conditions in counterbalanced order.

Results indicated that relative to their own baseline, children demonstrated higher pain thresholds and greater pain tolerance during both passive and interactive distraction. Moreover, although both distraction conditions were found to be effective, interactive distraction was superior to passive distraction. Specifically, when compared with the children in the passive distraction group, children in the interactive distraction group demonstrated significantly higher pain thresholds and tolerance.

In a less complicated design employing a more common interactive distraction tool, Patel et al. (2006) explored the efficacy of utilizing a handheld video game to reduce preoperative anxiety. One hundred and twelve children (ages 4-12 years) were randomly assigned to one of three groups: 1) parent presence; 2) parent presence and handheld video game; or 3) parent presence and oral premedication (0.5 mg midazolam). Children in the handheld video game group were allowed to play a game of their choice for at least 20 minutes prior to entering the operating room and during introduction of the anesthesia mask.

Results indicated lower levels of anxiety in children in the video game group at induction of anesthesia compared with children in the other two groups. Moreover, when comparing change in anxiety within patients (i.e., from baseline to induction of anesthesia), 63% of children in the video game group had no change or a decrease in anxiety compared with 26% in the premedication group and 28% in the parental presence only group. This finding is particularly significant because the introduction of the anesthesia mask has been shown to be one of the most stressful moments during anesthesia (Kain et al. 1996a). With interactive video game distraction, the current study was able to demonstrate reduced levels of anxiety to a greater degree than either parental presence alone or premedication.

In contrast to these findings, some studies suggest that in certain situations passive distraction may be more efficacious than active distraction. For example, MacLaren and Cohen (2005) randomly assigned 88 children (ages 1-7 years) receiving veni-puncture to one of three conditions: 1) interactive toy distraction; 2) passive movie distraction; or 3) standard care. Children in the passive condition exhibited less distress than children in the interactive condition. One explanation for this finding is that children in the active condition who became overwhelmed or who were not interested in the toy simply stopped playing, whereas children in the passive condition continued to receive the distraction regardless of their willingness to interact with the stimulus. These results highlight the importance of considering individual factors (e.g., age, interest) when selecting a distraction strategy.

Taken together, it appears that the efficacy of distraction varies some across type of situation and depends on the nature of the chosen distraction technique. Specifically, multisensory, active distraction is efficacious as long as the stimulus is one that will sufficiently interest the child and keep him or her actively involved. In instances in which a video game, for example, is not available, a pop-up book or an I Spy book can be used to actively engage the child in a task. In the absence of these tools, the use of a passive distraction technique appears to be more effective at reducing children's distress than no distraction at all.

Eliminating Stress and Anxiety From Your Life

Eliminating Stress and Anxiety From Your Life

It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.

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