As a pediatrician, I have a confession to make. I’m ashamed to admit that in residency I was amused when kids ramped up the drama getting shots. I’m not talking about a sadistic pleasure watching a 4 year old get poked repeatedly, I’m talking about an artistic appreciation of the wailing, screaming, and ninja-like thrashing performance when the nurse brought in the tray and….cleaned the child’s arm. With cotton. Gently. Yep, it was hard not to restrain a snicker when you alerted the child that, far from being near death from pain, the procedure hadn’t started yet. See? Cotton.
As a pain researcher, I now know that fear dramatically increases pain perception. Not only that, but focusing on the site where you expect pain naturally enhances your body’s perception of pain. Just like focusing on bite of gourmet food enhances your perception of nuances of the flavor (“Oh, cilantro!”) focusing on a painful procedure enhances that pain to occupy your entire consciousness. Not great if you don’t want pain.
Needle Phobia slide2Pain relief has become a major focus of medical professionals and children’s hospitals in recent years. While topical anesthetics have been around for decades, only 7% of pediatricians use methods to decrease the pain of needles. Recent innovations to address pediatric pain have been introduced, in part due to the realization that needle fear has jumped from 25% to 63% of children. This 252% increase is theorized to result in part because there are five times more live-saving vaccines that are now routine, and the realization that some vaccines need to be given at older ages to work well. Older age means kids remember the event, have greater cognitive powers to focus on the event, and thus can develop ongoing issues with needles when they experience vaccines as traumatic..
One physiologic way to deal with pain has been spotlighted here before, putting the cold and vibration unit Buzzy “between the brain and the pain”. The body feels sensations of cold and massage, and has less bandwidth to perceive pain. The sensation can even be disrupted, just like cold running water eliminated the pain of a burned finger. What I realized soon after developing Buzzy, however, was that a kid who is bound and determined to let you know how much they hate shots can feel pain from an alcohol swab. For a highly anxious kid who hasn’t seen Buzzy before, the explanation of “how this is going to make it better” might even focus them more on the procedure. I realized I needed something to help the child who is already afraid…something to decrease the fear AND take the focus off the poke.
Fortunately, kids have amazing imaginations, and — Ooh, look at that! —are pretty easy to distract. An easier, faster, and less expensive way to address pain and even boredom comes from the delightful curiosity kids have about new things, especially when they’re brightly colored. The very trait in kids that can be frustrating in long lines or car trips can actually be a huge advantage in managing pain. In fact, some of the more traditional hospital distractions (blowing up a balloon, etc.) had been proven to decrease children’s distress with medical procedures consistently by about 50%… But for this situation – for the child walking in terrified – we needed something more…but what? And thus, the DistrACTION cards were born….
Pain Fear and FocusWhat we’d learned was that controlling pain wasn’t enough for anyone – Fear, Focus on the procedure, and Pain all contribute to the experience.
To optimally pull a child’s attention away from a painful procedure, Child Life therapists use a variety of techniques, from blowing out (pinwheels, balloons, deep breathing) to visual distractions, both passive (videos) and active (Where’s Waldo??). Pulling from the distraction pain literature, I distilled the elements that seemed to be most helpful. In a stressful situation, too much difficulty (math problems) can be counterproductive. This is why “Where’s Waldo”, while a good active distraction, is actually less effective for most medical situations: he’s just too hard to find. The concept, though, is useful – visual active tasks like finding work well. Adding rote elements like counting can be good, but it depends on how hard it is to find something. “How many of something can you find” can be too easy if they’re right there – you could stop after one. “Find 6 of something”, however, is a concrete task which adds visual input to the cognitive task and gives the comfort of rote familiarity. The trick is distracting effectively for the right situation, giving just the right amount of challenge with the comforting ritual of counting. It’s that simple.
Purple cow DistrACTION cards have 10 questions on the back of each one, stratified by age groups.
They include questions that require simple finding for younger kids (Where is a purple cow?) with some questions that only adults could get (Can you find all the suits in a deck of cards?) Classic counting, how many cows?, was found to be too easy for older kids, so questions add difficulty by asking “How many cows are wearing a costume?”)
After creating the DistrACTION® Cards for medical procedures, investigators around the world started testing them.
Bees on hospital bed during IVFirst, Buzzy plus Distraction was tested for IV access in Turkey. Used correctly, Buzzy decreases needle pain 50-80%, and has been highlighted in Phlebotomy Today as a way to help draw blood in anxious patients. When DistrACTION is added, both together reduce pain from IV insertion 88%.
Investigators then started evaluating the DistrACTION cards alone. In the first study, pain was reduced 50% with the “Monkeys” set of cards alone; even cooler, 97% of kids said the procedure was better than previous times they’d had blood drawn.
Subsequent studies comparing other Child Life techniques found that DistrACTION cards decreased pain more than playing with a kaleidoscope; another study found the cards more effective than blowing a balloon, or playing a singing cartoon game.
The DistrACTION cards have now been clinically proven in three studies to be even better than other distractors in hospitals
Boredom busterBeyond pain management though, we found a terrific secondary benefit. When you can distract a child well enough to reduce pain in an unfamiliar environment, adding DistrACTION cards to a situation that is “merely boring” is extremely effective. From a 2 hour junior high concert recital to (one emergency nurse admitted) sitting through Mass, the cards have been extremely helpful for everyday behavior support. They’re waterproof, so they even work on the beach. No batteries, no screens – who knew?
I think the coolest thing for me has been that now, I get amused when a child seems very anxious, starts to ramp up the drama… and then is told “It’s already done!” As kids learn how distraction helps them deal with their own pain, the lesson sticks, even when there are no cards around. At a recent doctor visit for HPV vaccination, my older son said “Wait! You don’t have DistrACTION cards? Ok, ok, no problem…” he looked around the room and found red, blue and yellow speckles on the tile floor.” “No problem. When I need the shot, I’m counting confetti!” When he didn’t even flinch with the poke he was almost as proud of himself as I was!
- Distraction is an extremely effective parenting technique for multiple situations quite apart from pain management. Trouble starts brewing when children get bored, but a child who learns how to entertain themselves will have that skill their whole lives.
It’s critical to not depend on a battery powered source for distraction – whether it’s a small book, Distraction cards, or a small pot of play-dough, props help avert a boredom-induced meltdown. Once you learn the level of difficulty that keeps a kid engaged, the world around becomes a perfectly good distraction. “OK, I spy with my little eye…”
YOU are the best distraction for your child. While older kids can ask each other questions or read the questions on the back of the cards themselves, human interaction keeps a distraction interesting.
- For injections and medical procedures, there’s a difference between offering distraction and forcing a kid not to watch. Let the 20% of kids who prefer to view the procedure do so – it may be it’s own distraction for them, or a way for them to feel in control of the situation so they’re less afraid.
This blog post was initially published on Pediatric Safety