Journal of Pediatric Psychology Advance Access originally published online on February 23, 2005
Journal of Pediatric Psychology 2005 30(7):623-628; doi:10.1093/jpepsy/jsi048
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
When Distraction Fails: Parental Anxiety and Children’s Responses to Distraction during Cancer Procedures
1 Department of Psychology, University of Maryland Baltimore County, and 2 Division of Behavioral Health, A. I duPont Hospital for Children
All correspondence concerning this article should be addressed to Lynnda M. Dahlquist, Department of Psychology, UMBC, 1000 Hilltop Circle, Baltimore, Maryland 21250. E-mail: dahlquis{at}umbc.edu.
Received February 13, 2004; revisions received June 24, 2004 and August 13, 2004; accepted August 15, 2004
 |
Abstract |
|---|
 Top Abstract MethodResultsDiscussionAcknowledgmentReferences |
|---|
Objective To examine parental anxiety in the context of successful and unsuccessful distraction treatment of preschool aged children undergoing chemotherapy procedures. Methods Twenty-nine children (M age = 42 months) experiencing intramuscular or portacatheter injections participated in the study. Parents and children were shown how to use a portable electronic toy as a distractor during chemotherapy injections. Parental anxiety was assessed at baseline and child distress was coded during each procedure. Results Parents’ baseline state anxiety accounted for 17% of the variance in changes in children’s distress following distraction intervention. Parents of children who did not benefit from distraction reported significantly higher state anxiety at baseline than parents of the other participants. Conclusions Results highlight the importance of examining individual outcomes in intervention studies and suggest that parents’ emotional states may moderate distraction treatment outcome in young children. Future research formally testing parent anxiety as a moderator is recommended.
Key words: children; distraction; parents; anxiety; distress; medical procedures.
In recent years, considerable progress has been made in the development of effective distraction interventions for children experiencing medical procedure related pain (see Powers, 1999, Dahlquist, Jones, & McKenna, 2003, for reviews). However, the distraction literature suffers from many of the same limitations Kazdin (2003) recently noted in the child psychotherapy outcome literature. Despite the existence of therapeutic interventions with strong empirical support, research identifying the mechanisms of therapeutic change and the moderators of treatment effectiveness is lacking. Few investigators have examined the variables that relate to successful or unsuccessful distraction interventions.
Considering the results of intervention at the individual subject level can provide valuable information that is not necessarily apparent when mean group differences are evaluated. For example, examining treatment failures may help identify important theoretical and practical moderators of treatment effectiveness, enhance understanding of the process involved in therapeutic change, and ultimately help determine what intervention may be best for a particular child.
In a review of the pediatric distraction literature, we found only a few studies that discussed treatment failures. Most were single subject design studies in which one or two participants did not respond well to intervention or failed to maintain treatment gains. Anecdotal explanations for treatment difficulties included: inconsistent parental prompting to use the distractor (Pringle et al., 2001
; Dahlquist, Busby et al., 2002), autocratic parenting attitudes (Pringle et al., 2001), anxious-appearing parent behavior (Blount, Powers, Cotter, Swan, & Free, 1994), and traumatic medical experiences (e.g., multiple unsuccessful attempts to start an intravenous line or an especially frightening or painful procedure) during intervention (Pringle et al., 2001; Slifer et al., 2002).
Treatment failures have been discussed less commonly in group design studies. As a whole, younger children (under the age of 5 or 6 years) have been reported to have poorer responses to some distraction interventions (e.g., Fowler-Kerry & Lander, 1987; Manne, Bakeman, Jacobsen, Gorfinkle, & Redd, 1994) or to require more intervention sessions or more staff prompting before demonstrating therapeutic effects (e.g., Kuttner, Bowman, & Teasdale, 1988). Children with higher baseline distress also have been found to respond less favorably to distraction (Manne et al., 1994).
Taken together, the limited information available suggests that the age of the child, traumatic experiences, and parental variables, such as anxiety, prompting to use distraction, and parenting style, may play an important role in the success or failure of distraction intervention. Because of the important role that parents play in helping young children learn to regulate affect (Kopp, 1989), parental anxiety may be a particularly important determinant of the preschool child’s response to distraction intervention. However, to our knowledge, the role of parental anxiety as a moderator of treatment outcome has not been specifically tested.
The present study examines parental anxiety in the context of successful and unsuccessful distraction treatment of preschool aged children with cancer undergoing intramuscular (IM) injections and portacatheter (PC) access for chemotherapy administration. The distraction activity, which involved an interactive electronic game, was effective in reducing overt behavioral distress as well as parent and nurse ratings of the children’s distress (see Dahlquist, Pendley, Landthrip, Jones, & Steuber, 2002, for a detailed account of the intervention procedures and outcome data.) The present study presents a secondary analysis of the Dahlquist et al. (2002) outcome data.
|
Method |
|---|
|
TopAbstractMethodResultsDiscussionAcknowledgmentReferences |
|---|
Participants
Twenty-nine children with cancer who were undergoing outpatient chemotherapy and their parents participated. The 22 boys and 7 girls were between the ages of 29 and 62 months (M = 42.13, SD = 9.46). Sixteen children were Caucasian, eight were Latino, four were African American, and one was Asian American. The parent who typically accompanied the child to clinic (4 fathers, 25 mothers) was asked to participate. Parents ranged in age from 19 to 40 years (M = 29.78, SD = 4.97 years). Hollingshead (1975) socioeconomic status (SES) scores averaged 3.13 (range = 1–5). The children entered the study a median of 3.2 months after diagnosis. At the time of the study, topical anesthetics were not used for IMs or PCs.
Materials
Distraction was provided via a Texas Instruments Touch and Discover (Dallas, TX) 30.48 x 30.48 x 5.08 cm portable electronic toy with interchangeable picture panels depicting animals, shapes, household items, etc. The voice of Mickey Mouse instructed the children to find various pictures. When the child touched a picture, the toy emitted a sound (e.g., animal or mechanical noise) and Mickey indicated if the response was correct or prompted the child to try again.
Measures
Parent Anxiety. Parents completed the State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Luschene, 1983) prior to the first baseline assessment. This widely-used questionnaire consists of 40 Likert-type items that assess general dispositional tendencies (Trait Anxiety) as well as the respondent’s current, transient emotional state (State Anxiety). Higher scores denote greater anxiety. Psychometric properties of the scale are excellent. Nonclinical gender-specific adult norms were used.
Parents also used 7-point Likert-type scales anchored and "not at all anxious" and "very anxious" to report their anxiety while waiting for each chemotherapy procedure. Average parent pre-chemotherapy anxiety ratings were then calculated for the three distraction sessions and for the three baseline chemotherapy administrations immediately prior to distraction.
Child Overt Distress. The Observation Scale of Behavior Distress (OSBD; Jay, Ozolins, Elliott, & Caldwell, 1983) was used to code the presence or absence of verbal, vocal, and motor indicators of distress during 15-second continuous intervals. Separate scores were calculated for (1) the minute prior to the nurse first touching the child (the anticipatory phase—a time period in which many children protest and try to avoid the procedure), and (2) from the nurse’s first touch to the needle insertion or extraction (procedural phase). Because many children showed virtually no distress once the needle was removed, we did not code the post-procedure phase of the procedure. The occurrences of each behavior were then summed over the respective phase, multiplied by the intensity weights specified in Jay et al. (1983), and then summed across all OSBD behaviors. To control for differences in procedure length, the resulting weighted total score was divided by the number of 15-second intervals involved in the phase, thus yielding two weighted mean per 15-second interval scores (anticipatory and procedural) for each procedure. A composite OSBD score was then calculated by averaging the anticipatory and procedural OSBD scores.
Following the medical procedure, parents and nurses independently rated the child’s anxiety during the procedure on a 7-point scale anchored "not at all anxious or upset’ and ‘extremely anxious or upset." Average parent ratings and average nurse ratings of the child’s anxiety during the procedure were then calculated for the three distraction sessions and for the three baseline chemotherapy administrations immediately prior to distraction.
Procedure
Design. Children were randomly assigned to either a distraction (n = 18) intervention or a wait-list control (n = 12) condition. During the distraction intervention, children and their parents received brief (5 min) scripted verbal instruction in ways to use the Touch and Discover toy as a distractor during chemotherapy injections. Parents were instructed to prompt the child to play with the toy throughout the chemotherapy administration. Experimental subjects were videotaped during three baseline injections and three injections during which distraction was provided. Wait-list controls were videotaped during six baseline injections after which they also received the distraction intervention.
Videotaping. Participants were videotaped while receiving chemotherapy administered via IM injection or via subcutaneous PC access. Because the two procedures differed in duration, only one type of administration was observed for each child. Filming began when the child entered the examination room and ended approximately 2 min after the needle was removed or taped in place. The videotapes were coded by undergraduate and graduate students trained to a minimum reliability standard of kappas of .70 (Cohen, 1968) and 90% interval agreement on the OSBD. Approximately 20% of the videotaped chemotherapy administrations were independently coded by a second observer. The mean kappa was .72. Children who showed no overt distress (i.e., had OSBD scores less than 1.0) were excluded from the analyses. Consequently, 12 wait-list control subjects were observed for six baselines before receiving the distraction intervention; 18 experimental subjects were observed for three baselines before beginning the distraction intervention.
|
Results |
|---|
|
TopAbstractMethodResultsDiscussionAcknowledgmentReferences |
|---|
Preliminary analyses
The means and standard deviations of the independent and dependent variables were as follows: baseline composite OSBD = 4.84 (SD = 2.87); distraction composite OSBD = 3.08 (SD = 2.47); parent state anxiety = 52.59 (SD = 10.29); parent trait anxiety = 56.11 (SD = 12.83). Because the composite OSBD scores were significantly positively skewed, a square-root transformation was conducted. The transformed scores were used in all subsequent analyses unless otherwise noted.
Mean baseline OSBD scores were negatively related to the child’s age, r = -.41, p = .028, and to months since diagnosis, r = -.36, p = .05, but were not significantly related to parent state or trait anxiety or to parent prechemotherapy anxiety ratings, all rs 
.14, p > .46. Neither parent state anxiety, parent trait anxiety nor parent prechemotherapy anxiety ratings was significantly related to child age, months since diagnosis, or baseline OSBD distress scores.
Predictors of response to distraction intervention
In order to examine the degree of improvement demonstrated by each of the 29 participants (regardless of whether the child received the distraction intervention after three baselines or after six baselines), we regressed the mean composite OSBD score obtained during distraction intervention on the mean composite OSBD score obtained during the last three baseline observations (Cohen & Cohen, 1983). The resulting standardized residuals (residualized change scores) represent change in OSBD distress during distraction intervention. Negative numbers indicate decreases in distress.
Residualized change scores were significantly related to parent state anxiety, r = .37, p = .049. Residualized change scores were not significantly related to parent trait anxiety, parent baseline prechemotherapy anxiety ratings, the child’s mean baseline composite OSBD score, or to the child’s age, parent’s age, months since diagnosis, or SES, all ps > .25.
Hierarchical multiple regression analyses were conducted to further examine the degree to which parental anxiety was associated with changes in child distress during distraction. Since age and months since diagnosis were associated with baseline OSBD distress scores, they were controlled in the first step of the analysis. The resulting R of .283 was not significant, F(2,26) = 1.128, p = .33. To control for the possibility that the parent’s state anxiety was primarily a function of the child’s baseline distress, the child’s mean baseline composite OSBD score was entered next. R did not change, p = .95. Parent state anxiety was entered next. After controlling for age, months since diagnosis and baseline child distress, parent state anxiety contributed an additional 17% of the variance in residualized change scores, R = .502, F change = 5.53, p = .027. (See Table I)
|
Examining treatment failures
Although power is diminished when variables are dichotomized rather than considered continuously, findings sometimes become more easily understood when viewed in terms of group membership. Therefore, we examined the subgroup of children who did not appear to benefit from the distraction intervention in an exploratory analysis. Children were classified as treatment failures if their residualized change scores reflected an increase in OSBD distress of a magnitude greater than .49, which was equal to half the SD of the distribution of residualized change scores for the entire sample (M = 0, SD = .98).
A 2 x 2 repeated measures analyses of variance with treatment outcome (success or failure) as the between subjects variable and time (baseline vs. distraction) as the within subjects variable, was conducted on parent ratings of the child’s anxiety during the medical procedure. Results indicated a significant time by treatment outcome interaction, F(1,27) = 4.08, p = .05. Successfully treated children demonstrated greater reductions in parent ratings of child anxiety during the distraction intervention (from a mean of 4.58 at baseline to a mean of 2.94 during distraction) than did unsuccessfully treated children (baseline M = 4.21; distraction M = 3.58).
An identical analysis with nurse ratings of child distress during the medical procedure as the dependent variable also resulted in a time by treatment outcome interaction F(1,27) = 12.22, p = .002. Nurses rated successfully treated children significantly lower in anxiety during the distraction intervention than during baseline (baseline M = 4.62; distraction M = 3.69). In contrast, the nurse ratings of unsuccessfully treated children’s distress during procedures did not improve during distraction (baseline M = 3.94; distraction M = 4.18).
T-test comparisons revealed that the parents of children who were treatment failures (n = 11) had significantly higher state anxiety scores (M = 59.09 vs. 48.61) than parents of the other participants (n = 18). Groups did not differ with respect to child age, months since diagnosis or baseline OSBD distress levels, all ps > .17.
A logistic regression analysis was conducted to determine the degree to which child age, months since diagnosis, parent state anxiety, parent prechemotherapy anxiety ratings, and the child’s baseline OSBD distress could be used to correctly classify children as ‘treatment failures.’ The logistic regression model correctly classified 9 of the 11 treatment failures (81.8%) and 26 of the 29 children in the total sample (89.7%). Examination of the individual coefficients presented in Table I revealed that parent state anxiety contributed most significantly to the prediction equation.
|
Discussion |
|---|
|
TopAbstractMethodResultsDiscussionAcknowledgmentReferences |
|---|
The results of this investigation suggest that parent anxiety may play an important role in children’s responses to distraction intervention. The children who did not respond favorably to distraction had parents who were significantly more anxious than the parents of their counterparts. Although parents’ state anxiety scores did not reach clinically elevated levels (T-scores were not above 70), the differences were not trivial. The scores of the treatment failure group were more than a standard deviation higher than the rest of the sample. This finding did not appear to merely reflect parents’ responses to elevated distress levels in their children. Baseline distress was not higher in the treatment failure group. Moreover, when the child’s baseline level of distress was controlled, differences in parental state anxiety were still associated with treatment outcome.
In a recent review of the parent’s role in children’s coping with stress, Power (2004) argued that parents influence (1) children’s exposure to potentially stressful events, (2) children’s appraisals of potential stressors—for example in terms of threat, significance, or manageability, and (3) the ways in which children cope with stress. Anxious parents may influence their children’s ability to benefit from distraction through any of these pathways. For example, anxious parents may be overly protective. They may restrict the child’s opportunities to interact with the environment to such a degree that the child may be less competent in dealing with stressors in general (Power, 2004), and therefore less able to use distraction to regulate affect during medical procedures.
Anxious parents may influence children’s appraisals by behaving in ways that lead the child to perceive the medical procedure as unmanageable, even when provided with a distraction coping strategy (e.g., via negative comments about the distractor, frequent references to the pain of the procedure, or criticism of the child’s use of the distractor). Or, something about the way that anxious parents instruct the child to use the distractor may somehow communicate a greater sense of threat to the child, in much the same way that parental agitation, reassurance, and excessive explanation have been shown to be associated with elevated distress during medical procedures and physical examinations (Bush, Melamed, Sheras, & Greenbaum, 1986; Blount et al., 1989; Dahlquist, Power, & Carlson, 1995; Power, 2004).
Finally, anxious parents may be less effective in helping their children use the distractor. A number of studies have demonstrated that parents who have high levels of emotional distress are less sensitive, less responsive, and less nurturing in their interactions with their children (e.g., Belsky, Crnic, & Woodward, 1995; Gondoli & Silverberg, 1997; Power, 2004). The more anxious parents in the present study may have been less likely to notice positive coping efforts in their children and less likely to praise them when they used the distractor or remained calm.
On the other hand, it is possible that parent anxiety and children’s responses to distraction were correlated for other reasons. For example, parents of children with poor affect regulation skills or a history of traumatic medical experiences may evidence elevated state anxiety and their children may respond more poorly to distraction. Parent state anxiety and children’s responses to distraction intervention also could be correlated because of relations to another variable that has little to do with distraction—that is, with the child’s prognosis or the child’s cognitive skills—but may still be related to both parent anxiety and the child’s ability to benefit from distraction. The correlational nature of the data precludes any conclusions about the direction of effects.
The implications of the current findings also are limited by the small and potentially unrepresentative sample. Replication is needed with a larger sample and with parent anxiety examined a priori as an independent variable. This would allow for more formal testing of parental state anxiety as a moderator of treatment outcome, the results of which could have important clinical implications. Children whose parents demonstrate elevated state anxiety may need different interventions for procedural distress or their parents may need training in specific skills (e.g., relaxation) in order to implement distraction protocols.
|
Acknowledgment |
|---|
|
TopAbstractMethodResultsDiscussionAcknowledgmentReferences |
|---|
The authors thank Cheri Jones and Donna Landthrip for their help in data collection and coding, Donald Fernbach, M.D., David Poplack, M.D., C. Philip Steuber, M.D., and the staff and families of the Texas Children’s Cancer Center for their support, and Tom Power for his helpful comments on the manuscript.
|
References |
|---|
|
TopAbstractMethodResultsDiscussionAcknowledgmentReferences |
|---|
Belsky, J., Crnic, K., & Woodward, S. (1995). Personality and parenting: Exploring the role of transient mood and daily hassles. Journal of Personality, 63, 905–929.[CrossRef][Web of Science][Medline]
Blount, R. L., Corbin, S. M., Sturges, J. W., Wolfe, V. V., Prater, J. M., & James, L. D. (1989). The relationship between adult’s behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behavior Therapy, 20, 585–601.[CrossRef][Web of Science]
Blount, R. L., Powers, S. W., Cotter, M. C., Swan, S., & Free, K. (1994). Making the system work: Training pediatric oncology patients to cope and their parents to coach them during BMA/LP procedures. Behavior Modification, 18, 6–31.
Bush, J. P., Melamed, B. G., Sheras, P. L., & Greenbaum, P. E. (1986). Mother-child patterns of coping with anticipatory medical stress. Health Psychology, 5, 137–157.[CrossRef][Web of Science][Medline]
Cohen, J. (1968). Weighted Kappa: Nominal scale agreement with provision for scale disagreement or partial credit. Psychological Bulletin, 70, 213–220.[CrossRef][Medline]
Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation analysis for the behavioral sciences (2nd ed.). New York: Lawrence Erlbaum.
Dahlquist, L. M., Busby, S. M., Stifer, K. J., Tucker, C. L., Eichen, S., Hilley, L., & Sulc, W. (2002). Distraction for children of different ages who undergo repeated needle sticks. Journal of Pediatric Oncology Nursing, 19, 22–34.
Dahlquist, L., Jones, K., & McKenna, K. (2003). Empirically supported treatment bibliography: Procedure-related pain update. Retrieved February 3, 2004, from http://www.apa.org/divisions/div54/estupdates2003.htm
Dahlquist, L., Pendley, J., Landthrip, D., Jones, C., & Steuber, C. P. (2002). Distraction intervention for preschoolers undergoing intramuscular injections and subcutaneous port access. Health Psychology, 21, 94–99.[CrossRef][Web of Science][Medline]
Dahlquist, L., Power, T., & Carlson, L. (1995). Physician and parent behavior during invasive cancer procedures: Relationships to child behavioral distress. Journal of Pediatric Psychology, 20, 477–490.
Fowler-Kerry, S., & Lander, J. R. (1987). Management of injection pain in children. Pain, 30, 169–175.[CrossRef][Web of Science][Medline]
Gondoli, D. M., & Silverberg, S. B. (1997). Maternal emotional distress and diminished responsiveness: The mediating role of parenting efficacy and parental perspective taking. Developmental Psychology, 33, 861–868.[CrossRef][Web of Science][Medline]
Hollingshead, A. B. (1975). Four Factor Index of Social Status. New Haven, CT: Yale University.
Jay, S. M., Ozolins, M., Elliott, C. H., & Caldwell, S. (1983). Assessment of children’s distress during painful medical procedures. Health Psychology, 2, 133–147.
Kazdin, A. E. (2003). Psychotherapy for children and adolescents. Annual Review of Psychology, 54, 253–276.[CrossRef][Web of Science][Medline]
Kopp, C. B. (1989). Regulation of distress and negative emotions: A developmental view. Developmental Psychology, 25, 343–354.
Kuttner, L., Bowman, M., & Teasdale, M., (1988). Favorite stories: a hypnotic pain-reduction technique for children in acute pain. American Journal of Developmental and Behavioral Pediatrics, 9, 374–381.
Manne, S., Bakeman, R., Jacobsen, P., Gorfinkle, K., & Redd, W. (1994). An analysis of a behavioral intervention for children undergoing venipuncture. Health Psychology, 13, 556–566.[CrossRef][Web of Science][Medline]
Power, T. G. (2004). Stress and coping in childhood: The parents’ role. Parenting: Science and Practice.4, 275–321.
Powers, S. (1999). Empirically supported treatments in pediatric psychology: Procedure-related pain. Journal of Pediatric Psychology, 24, 131–145.
Pringle, B., Hilley, L., Gelfand, K., Dahlquist, L. M., Switkin, M., Diver, T., et al. (2001). Decreasing child distress during needle sticks and maintaining treatment gains over time. Journal of Clinical Psychology in Medical Settings, 8, 119–130.
Slifer, K., Eischen, S., Tucker, C., Dahlquist, L. M., Busby, S., Sulc, W., et al. (2002). Behavioral treatment for child distress during repeated needle sticks. Behavioral and Cognitive Psychotherapy, 30, 83–94.
Spielberger, C. D., Gorsuch, R. L., & Luschene, R. E. (1983). Manual for the state-trait anxiety inventory. Palo Alto: Consulting Psychologists Press.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  J. W. Varni, C. Limbers, and T. M. Burwinkle Literature Review: Health-related Quality of Life Measurement in Pediatric Oncology: Hearing the Voices of the Children J. Pediatr. Psychol., October 1, 2007; 32(9): 1151 - 1163. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||