Psychological Methods

Parental Behavior

SHOW CONFIDENCE

Children can tell how confident you are about their pain management. In fact, children say parents are their greatest source of strength when dealing with pain. But they can also react to parents' anxiety about pain. Understandably, parents can feel overwhelmed by their child's illness and the pain they think he or she may have to endure. If this is the case, it is best to ask for help to deal with the situation. Your own doctor, one of the doctors caring for your child, or the nurse can tell you what resources are available.

GIVE EXPLANATIONS THE CHILD CAN UNDERSTAND

Children need to know what is happening to them. They should be given explanations about what they will feel, hear, and smell in a way they can understand. A young child will need a different explanation than a 16 year old. For example, younger children are often helped by using a doll to show what is to be done, but adolescents may respond better to diagrams.

INDIVIDUALIZE THE APPROACH

Each child is an individual. Something that helps one child may not help another. Some children like to know exactly what is going on during a procedure. Others want only a few details. Some children like to know things long before they happen, while others like to find out closer to the time. As a parent, you will have a good idea how your child might react. Older children and adolescents should be asked directly what they prefer. And in all cases, careful observation will make many preferences clear.

BE HONEST

It is always a mistake to lie to a child about pain. Children who are wrongly told a painful treatment or procedure won't hurt will have little trust the next time. Children's fears and pains should also be accepted. For example, you could say: "I know this medicine stings when it goes in." Follow this with some help, for example: "...but if you take a breath and blow out slowly, it may hurt less."

GIVE POSITIVE FEEDBACK

Children respond well to praise. Co-operative behaviour should be encouraged. Statements like: "I was pleased to see you trying to stay still" or "It was good you told the nurse exactly how you were feeling" can be helpful. Minor misbehaviour should be ignored, although, at times, a no-nonsense approach may help the child co- operate. Even children with serious illness need expectations of "good" behaviour. Small rewards, such as stickers, food treats, or a special activity, can help a child with painful procedures. Rewards should also be given for effort. Painful procedures are dif ficult, and the child who is trying to co-operate should have as much recognition as the child who is able to achieve it.

NEVER USE MEDICAL PROCEDURES AS A THREAT

When a child misbehaves, it is not fair to threaten him or her with a needle. This interferes with the child's sense of trust and can make behaviour worse.

GIVE SOME CONTROL TO THE CHILD

Children can be allowed to control some aspects of their treatment. As we said before, the feeling of being in control reduces pain. Even very young children can be allowed to decide some parts of their treatment, for example: whether to sit on your lap or a chair, which finger to have pricked, and/or whether to have a bandaid.

Child Behavior

USE PLAY

Play is an essential part of every child's life. Play is the way a child explores his or her world and becomes part of it. Play also helps children express feelings and "work through" issues that concern them.

Children who are sick can still play, although some children may need more help in their play. Most games, toys, and books can be brought to the bedside.

Small hospital furniture and medical supplies with dolls are especially good for helping children act out fears and anxieties. Medical play can also help us discover misconceptions a child has about his or her disease or medical treatment. Likewise, drama, art, music, writing, poetry, and puppetry can all help children talk about their illness and gain control over painful experiences.

Child-life specialists are specially trained to help your child enjoy playing while in hospital. They can also help you with ideas to help your child with play activities.

USE RELAXATION AND IMAGERY

Anxiety and tension can make pain worse. First, it is more dif ficult and more painful to put a needle in a tense muscle. When a child is relaxed, veins are easier tofind and bruising is reduced. Second, anxiety increases pain by opening "pain switches" in the brain. Anxiety also stops the brain from blocking the feeling of pain. Finally, anxiety uses up needed energy, decreases rest and sleep, and tires the child. All of these make it more dif ficult to cope with pain.

Relaxation is a useful way to combat pain. Regular relaxation exercises can, and ideally should, be started before a speci fic problem has occurred. We suggest, for example, that relaxation techniques be learned in the first couple of weeks, or as soon as possible after the initial diagnosis. That way, you and your child will know how to use these techniques when they are really needed.

Some helpful relaxation techniques are described below. In addition, there is a script at the end of the book which presents three types of relaxation exercises. As always, the doctors and nurses caring for your child should also be able to help you and your childfind the best approach.

Different forms of relaxation are better for different ages. Babies relax with rocking, cuddling, sucking on a sweetened soother, gentle stroking, soothing talk, and lullabies. For instance, a heel- or fingerprick will be less painful if a baby is cuddled and has a soother.

Toddlers and preschoolers relax with many of the techniques used for babies. They also enjoy stories, and often love hearing the same one over and over. A favourite teddy bear or blanket is often comforting. Listening to or singing a familiar song may also relax them.

School-aged children often enjoy cuddles and a gentle massage by parents. Reading may relax some children, while for others it can be a chore. Children over 10 years may be able to learn formal muscle relaxation. In addition, "pleasant imagery" (such as recalling a favoured activity), or taking deep slow breaths, may help relax them. The script that comes with this book describes both pleasant imagery and muscle relaxation for this age group.

Most teenagers can readily learn muscle relaxation and deep slow breathing. Many of the techniques used with younger children (cuddles, being read to, massage) will also comfort an older child. Adolescents will also have comfort objects, such as a favourite sweater, a small stuffed toy, or a good luck charm.

The stress of having a child with cancer is considerable and many parents find it helpful to learn relaxation methods for their own use.

USE DISTRACTION

Distraction is especially helpful for short pain, such as pain from fingerpricks. All ages of children can be distracted with music, action videos, or TV. For some, music through earphones (such as a Walkman¬) is particularly useful.

Babies can be distracted by dramatic talking: "Oh Mary we are just going to do this as quickly as we can." Showing a baby something interesting, such as a squeaky toy or anything bright and moving, will help take their attention off the painful procedure.

Preschoolers and early school-aged children can be distracted with a pop-up book or a detailed and interesting picture book. Blowing bubbles and party blowers are also great for this age group.

Older children and adolescents can be distracted by conversation. Talking to them about past, present, or future events will help take their mind off the procedure.

TEACH SELF TALK

Children and adults talk to themselves. "Self talk" can be calming and helpful for some children, while for others it may cause more anxiety.

Some examples of useful self talk include: "This will be over soon", "I can handle this", "It's tough but I am doing well", "This will help me in the long run". Children above about 6 years of age can be coached during a procedure to say calming and relaxing things to themselves. After about age 10 years, children can learn to do this even when a "coach" is not there.

Older teenagers can learn a more sophisticated strategy. Called ADAPT (after thefirst letter in each step), this approach is as follows:

  • Acknowledge the negative feeling or thought.
  • Describe to oneself what statements or thoughts are causing the negative feeling.
  • Assess if the thoughts are helpful.
  • Present alternatives to the thoughts.
  • Think praise: Give yourself a pat on the back for a better way of thinking.

TEACH PROBLEM SOLVING

Older children and adolescents can learn what makes their pain worse, and what makes it better. Measuring pain and keeping a record of the ratings is helpful for problem-solving discussions. By comparing previous ratings, the child and parent or nurse canfigure out what helps pain and what makes it worse. Brainstorming can then be used tofind new ideas to help reduce the pain.

Summary

Infants 0-1 year: Rocking, stroking, patting, use of soother, food, distraction, music, soothing talk, new or favourite toy.

Toddler 1-3 years: Rocking, stroking, patting, use of food, distraction, music, soothing, self-talk, favourite stories read by parent or on tape.

Preschool and School-aged: Self talk, relaxation exercises, control, distraction, music or stories on tape.

Adolescent: Problem solving, self talk, relaxation exercises, control.