Jacobsen syndrome

TOPIC. The clinical nurse specialist's role as part of a multidisciplinary pain team in assessing and treating children with pain, and children with comorbid pain and a psychiatric diagnosis.

PURPOSE. To help nurse clinicians use relatively new assessment and treatment strategies in the arena of children's pain, gain a better understanding of pain's co-morbidity with psychiatric problems, and understand the nurse's important role in working with children with pain.

SOURCES. Published literature: Pain assessment, theories of pain, psychiatric assessment, pain and psychiatric co-morbidity, treatment modalities for pain. A case study of a teenage girl with chronic pain and a psychiatric disorder.

CONCLUSIONS. Nursing interventions in pediatric pain assessment and treatment play a vital role in the child's and adolescent's physical and emotional rehabilitation from pain and psychiatric symptoms.

Search terms: Adolescents, child psychiatric children, clinical nurse specialist, pain, psychiatric co-morbidity

Pain is defined by the International Association for the Study of Pain (IASP) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or defined in terms of such damage" (Sifford, 1997, p. 745). Because pain is subjective and unique to the individual experiencing it, self-report is the recommended foundation of pain assessment and management.

Multidimensional concepts of pain emphasize the physiologic, sensory, affective, cognitive, behavioral, and sociocultural factors that contribute to a patient's experience. Children's perceptions of and communication about pain replicate all these factors, as well as their developmental level and their previous pain experience (Sifford, 1997). Pediatric pain can be delineated into four categories: (a) pain associated with chronic diseases (e.g., arthritis, hemophilia, sickle cell disease, cancer); (b) pain associated with observable physical injuries or traumas (e.g., burns, lacerations, fractures); (c) pain not associated with a well-defined or specific chronic disease or identifiable physical injury (e.g., migraine and tension headaches, recurrent abdominal pain syndrome); and (d) pain associated with medical and dental procedures (e.g., lumbar punctures, bone marrow aspirations, surgery, injections, extractions) (Varni, Blount, Waldron, & Smith, 1995).

Theories of Pain

Among the several theories of pain are (a) the gate control model, (b) a biobehavioral model, and (c) the middle-range theory. The gate control model of pain response is based on physiologic evidence that pain perception (nociception) involves pathways in the dorsal horn of the spinal cord that relay noxious stimuli to the brain. In addition, nerve fibers function as an antagonist "gate" to augment or dampen the subjective experience of pain (Melzack, 1993; Melzack & Wall, 1965). Melzack and Wall's gate control model continues to influence current thinking about pain.

The cognitive-biobehavioral model (Turk, Meichenbaum, & Genest, 1983) considers not only the patient's emotive and cognitive perception of pain, but also the interaction of environmental influences, physical factors, and pain perceptions over time. From this perspective the patients' interpretations of pain, their coping resources, and their emotive-psychological processes interact with the experience of pain and can influence the physiologic activities that characterize pain (Turk & Marcos, 1994).

The middle-range theory is a nursing theory that focuses on acute pain management. The premises of the theory are that selected interventions contribute to a balance between analgesia and side effects; these interventions are: (a) giving adequate potent pain medication along with pharmacological and nonpharmacological adjuncts; (b) regular pain and side effects assessment, plus identification of inadequate pain relief and unacceptable side effects, plus a process of intervention, reassessment, and reintervention; and (c) patient teaching and goal setting for pain relief. Good and Moore (1996) hypothesize that medication, in combination with relaxation, nursing intervention (including preoperative teaching and postoperative pain management), and education will result in significantly greater pain relief.

Pediatric Pain History

The last 15 years have seen a dramatic increase in attention paid to children's pain. In the early 1980s it was not uncommon for infants to have surgery without anesthesia, to receive minimal postoperative or preprocedural analgesia, and for the myth to exist that children do not feel pain (Schecter, 1997). In a 1987 survey, only 30% of medical centers for children used premedication for children undergoing bone marrow aspirations or biopsies (Schecter). Clearly, we are still in our infancy in addressing children's pain. Nurses play an important role in advocating for a decrease in acute and chronic pain for children.

The Multidisciplinary Team and the Role of the Child Psychiatric Nurse

Advances in pain management are being made. Clinical practice guidelines have been developed by a number of professional societies and governmental and regulatory agencies. Multidisciplinary pain services have been developing across the world in the last 5 to 10 years (Schecter, 1997). The author, a clinical nurse specialist (CNS), worked in such a multidisciplinary pain team in a children's hospital. The team consisted of two anesthesiologists, a pediatric nurse practitioner specializing in the treatment of children's pain, and a CNS in child and adolescent psychiatry. The clinic served the outpatient population for one morning every other week, and the pain team treated inpatients on a daily basis.

The outpatient population consisted of children 5 to 18 years of age, most of whom had developed chronic pain problems. The types of pain treated covered a wide range of medical problems, including headaches and migraine; sickle cell anemia; head, neck, and back; leg injuries; juvenile rheumatory arthritis; cancer; hemophilia; traumatic injuries; and reflex sympathetic dystrophy

The CNS's role with the outpatient pain clinic included a psychosocial evaluation with each patient and family. In the inpatient setting, the psychiatric CNS was called to assess psychological reactions to a painful illness, trauma, or medical procedure; to evaluate mental status changes secondary to illness or treatment; to help children cope with anxiety related to medical procedures; to explore the use of psychotropic medications for pain; to assess the child's experience in which the medical team could find no etiology for the pain; and to assess children when their level of functioning is lower than expected given their physical illness.

The psychiatric evaluation is best done in the familiar medical inpatient or outpatient setting to assess responses to pain management interventions and changes in the child's level of functioning. Children who were identified as needing psychiatric treatment to cope with pain issues either would be followed as an inpatient by the consultation liaison clinician, be given an outpatient psychiatric appointment, or receive follow-up in the outpatient pain clinic. This clinician would see approximately eight patients a week with pain as a part of their clinical presentation.

Psychosocial Assessment

The interview for the child experiencing pain includes questions for both child and parent, and takes approximately 1 hour to complete. The interview begins with the pain history and includes a variety of questions and tools used for pain assessment (Table 1).

Standardized pain measures. Stevens (1997) evaluated several standardized pain measures in children, adolescents, and infants, and concluded that the Children's Comprehensive Pain Questionnaire (McGrath, 1990) had good reliability and validity The measure is useful with children 5 to 10 years of age who experience headaches, abdominal or limb pain, and other types of chronic pain. Stevens found the Adolescent Pediatric Pain Tool (Savedra, Tester, & Holzemer, 1989) to have good reliability and validity and to be useful for children ages 8 to 17 years. For infants, Stevens found the Riley Infant Pain Scale (Joyce, Schade, & Deck, 1994) demonstrated good reliability and validity in assessing pain in infants. Varni et al. (1996) developed a standardized questionnaire to assess systematically children's pain coping strategies. The Pediatric Pain Coping Inventory (PPCI) assessed five dimensions: cognitive self-instruction, seeking social support, strive to rest and be alone, cognitive refocusing, and problem-solving self-efficacy. Results of their research showed the PPCI is a conceptually valid and internally reliable measure for assessing pediatric pain coping strategies.

Mental status examination. The second portion of the psychiatric evaluation is the mental status examination (MSE). The MSE includes the child's appearance; orientation; fine- and gross-motor skills; mood; activity level; ability to pay attention; judgment and insight; intelligence and cognitive skills; language; thought content; developmental level; use of drugs, alcohol, or cigarettes; behavioral problems; sleeping and eating habits; presence of hallucinations or delusions; presence of obsessive thought or rituals; presence of suicidal or homicidal ideation; strengths; and peer relationships.

Research comparing children, parents, and nurses rating of pediatric pain. A few studies have explored the level of agreement between child and parent and nurse reports of pain. Chambers, Giesbrecht, Craig, Bennett, and Huntsman (1999) used five different pain scales and found the level of agreement between child and parent pain reports was low and did not vary as a function of the scale used; parents overestimated their children's pain using all five scales. Girls reported higher levels of pain than did boys, and age was not a significant factor.

Manne, Jacobsen, and Redd (1992) evaluated 85 pediatric cancer patients ages 3 to 10 years who were receiving venipuncture procedure to compare pain and distress ratings obtained from parents, pediatric patients, and nurses using self-report and observer ratings. Ratings varied among child, parent, and nurse. Nurses' ratings were based on the child's overt distress in pain response and the developmental level of the child. Parents' ratings reflected their subjective perception of the child's pain and their own anxiety. The child's self-report was associated with the child's chronologic age; younger children reported more pain. One of the hypotheses of this study was that children's fear and distress may decrease with age, not that pain experienced decreases with age.

Psychiatric co-morbidities and psychiatric pain disorders. Psychiatric illness often accompanies medical illness and is a significant healthcare problem among the medically ill. People with a chronic medical illness have a nearly 41% higher rate of psychiatric disorders than people without chronic medical illness (Kongable, 2001). The biological basis of co-morbid mental disorders in medically ill people is attributed to neurochemical changes in the process of catecholamine metabolism. When neurochemical modulation is disrupted mechanically or chemically, biopsychosocial disorders occur (Kongable).

For patients with medical conditions, pain can be modulated by psychiatric co-morbidity such as depression, bereavement, and anxiety disorders such as panic disorder, overanxious disorder, acute and post-traumatic stress disorder, and separation anxiety disorders (Sifford, 1997). Katon and Schulberg (1992) and Neese (1991) found that mood, anxiety, and substance use were the most prevalent psychiatric conditions of people with terminal or chronic illnesses such as chronic pain. Ruoff (1996) found that depression occurs in as many as 50% of chronic pain patients. Depression may develop secondarily or independently of the chronic pain syndrome, or it may occur as the primary cause of chronic pain. Depression and pain may share common biological pathways, namely, the serotonergic (5 HT) and noradrenergic systems (Ruoff).

There are also a cluster of psychiatric disorders classified as somatoform disorders involving pain that are clearly related to psychiatric etiology rather than having a medical cause for pain. Somatization is the process of expressing physical symptoms as a manifestation of psychological stress (Sifford, 1997). A somatoform disorder is when one or more physical complaints are present that cannot be explained by a medical condition. These disorders include somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, and hypochondriasis (Sifford). Garber, Zeman, and Walker (1990) found both children with recurrent abdominal pain with no identified organic cause of pain and those with identified medical cause for abdominal pain had significantly more psychiatric disorders than healthy controls. Both groups were primarily diagnosed with anxiety disorders and depressive disorders.

Psychiatric disorders, such as psychological factors affecting physical condition, anxiety, and depression, can worsen a child's ability to cope with a medical condition. Examples of children with medical problems who are debilitated by their psychiatric conditions are children with cerebral palsy and depression who lack motivation and energy to practice their exercises; when they attend physical therapy, the procedures are more painful due to muscle constriction because they have resisted using the physical therapy treatment. Another example is a child with a heart condition and generalized anxiety disorders, who experiences high levels of anticipatory anxiety about procedures, which results in severe temper tantrums, crying outbursts, and delayed or postponed medical treatments. Standard education, comfort, anxiety-reduction measures (e.g., staff and parent encouragement, education about the procedure), and comfort measures (EMLA cream for shots, holding a stuffed animal) provide no relief of anxiety or emotional comfort for this child because the anxiety disorder remains untreated.

Pain Management Interventions

There are several effective pain-management techniques. A comprehensive pain-management strategy to treat pain disorders with or without psychiatric co-morbidity can include a combination of pharmacological agents, mind/body techniques, and psychotherapy interventions.

Pharmacological Interventions

Pharmacologic interventions include both pain medications and psychopharmacologic agents. Pain medications include analgesics: (a) opioids (morphine, meperidine, methadone, fentanyl); (b) nonopiods (aceteminophen, acetylsalicylic acid, ibuprofen); and (c) partial agonists/ antagonists (oxycodone) (Leith & Weisman, 1997). Psychopharmacologic agents are useful in the treatment of chronic pain in children. Dahlquist (1999) recommends a medication assessment for a child's physical pain (Table 2). Antidepressants are useful in children largely based on a favorable experience with adult patients with neuropathic pain (Watson, 1994). Tricyclics for chronic pain such as headaches, denervation syndromes, and posttherapeutic and rheumatic pain have been found useful. Although ef festive for chronic pain, they have not been as effective a treatment for children's depression. Tricyclic medications include amitriptyline and nortriptyline (Leith & Weisman).

Serotonin reuptake inhibitors (SSRIs) are indicated when more symptoms of depression are present along with pain (Ruoff, 1996). To date, fluoxetine has been proven better than placebo in children with depression in a double-blind controlled study on 96 children and adolescents (Emslie et al., 1997). SSRIs include fluoxetine, paroxetine HCI, venlafaxine HCL, and setraline HCI. SSRIs are more useful to treat anxiety over a longer period of time. Anticonvulsants such as carbamazepine, gabapentin, clonazepam, and phenytoin are used to relieve neuropathic pain as they increase levels of brain seratonin, which is involved in the control of pain transmission (Merren, 1998; Pinelli, Trivulzio, & Tomasone, 1997).

Benzodiazepines (lorazepam, diazepam, midazolam) are good for one-time use or prn to decrease anxiety for procedures (Leith & Weisman, 1997); they are not good for extended use longer than 1 month due to their addictive properties.

The nursing middle-range theory is a useful tool when focusing on treatment of pain with pharmacological agents because it evaluates pain relief and side effects from medications. It also incorporates patient teaching and goal setting for pain relief. The cancer pain guideline panel (Management of Cancer Pain Guideline Panel, 1994) developed a pain-control record that includes the date, time, pain intensity rating, medication taken, pain intensity 1 hour after taking medication, and what the patient was doing when he/she felt the pain. This record could be used to evaluate the patients response to medications administered, incorporating the principles from the middle-range theory.

Mind-Body Interventions

Pain-management strategies need to address the mental, emotional, and physical aspects of the child. Mindbody methods are active treatments because they encourage the child's participation in treatment, thereby mobilizing coping and recovery skills. Mind-body strategies for pain management include relaxation therapy, behavioral distraction, hypnosis, and biofeedback. These mind-body treatments use the important theoretical concepts in the cognitive-biobehavioral model that take into account the cognitive, emotional, and environmental factors that can mediate a pain response.

Relaxation. Relaxation training aims to teach children to develop awareness and control over their own physiological and muscular reactions to anxiety. Relaxation therapy is a set of coordinated physiological changes that are brought forth when a person focuses attention on a repetitive mental activity and passively ignores distracting thoughts (Fentress, Masek, Mehegan, & Bensen, 1986). Examples of relaxation strategies include breathing methods, soothing music, visual imaging, and progressive muscle relaxation. A number of physiologic changes occur naturally with relaxation. The child's mind often begins to drift, there are changes in serotonin metabolism and other brain chemistry, aching muscles and ligaments soften with reduced tension, autonomic reactivity reduces, and heart rate and metabolism slow down (Kuttner, 1997).

Relaxation has been proven effective in several childhood studies for children with asthma (Kohen, 1996), pediatric emergencies (Kohen, 1986), and pediatric migraine (Fentress et al., 1986). Luebbert, Dahme, and Jadenbring (2001) evaluated 15 controlled studies for cancer patients and found significant positive effects for the treatment-related symptoms through relaxation therapy Relaxation training also proved to have a significant effect on the emotional adjustment variables of depression, anxiety, and hostility. Some examples of relaxation used with children indude progressive muscle relaxation, where children learn to flex and extend muscle groups in the body from head to toe, decreasing muscular tension. Children also are very responsive to imagery techniques, such as verbally walking them through a story of an enjoyable trip to the beach, where they might be asked to use their senses to imagine the sights, sounds, tastes, and feelings of the beach. Encouraging them to feel relaxed and pain free on the imaginary beach trip is a form of verbal suggestion to achieve an altered physiological or mental state, and alter pain symptoms. Other favorite places or events of the child can replace a beach imagery outing. Children may choose to think about a trip to the mountains, zoo, or a favorite place in their neighborhood. Deep breathing exercises are useful for children over the age of 7. Taking deep breaths works by distracting the patient from negative thoughts and focuses on breathing activity. Deep breathing prevents hyperventilation, which can occur when a child is anxious. Listening to calming music, such as sounds of the ocean, also is a useful relaxation strategy for children.

Behavioral distraction. Behavioral distraction is the active process of diverting attention from the hurt, pain, fear, and anxiety to something incompatible with those experiences (Blount, Schaen, & Cohen, 1999). Behavioral distraction is useful in that it prevents children from holding their breath and refocuses mental thoughts on enjoyable, playful activities such as blowing bubbles, counting their fingers or toes, reading stories, playing video games, or watching a favorite show. Behavioral distraction is useful during procedures such as shots or blood draws. When used by parents with their child, behavioral distraction was found to positively relate to children's coping and negatively relate to distress (Manne et al., 1992). In a comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations, Cohen, Blount, Cohen, Schaen, and Zaff (1999) found that out of 39 fourth graders receiving vaccinations, distraction resulted in more nurse coaching and child coping and less child distress than did topical anesthesia or typical care on an observational measure. Marine, Bakeman, Jacobson, and Redd (1993) found distraction and information seeking by children increased coping behaviors during the painful procedure of venipuncture in 45 children undergoing cancer treatment.

Hypnosis. Hypnosis has emerged over the last two decades as a successful primary or adjunct method of modifying pain perceptions in children and adolescents. Hypnosis works by altering the state of consciousness in which the child's perception of pain is facilitated to help the child gain a sense of empowerment and control of the pain (Kuttner, 1997). Hypnotic suggestions for pain reduction are aimed at promoting a safe distance or dissociation from the pain, distress, and trauma. An example of a hypnotic or suggestive method is when the clinician suggests visual images of unknotting or shrinking the size of the pain while the child is in a calm or trancelike state (Kuttner). Hypnosis has been found effective in treating the pain of children with cancer (Hilgard & LeBaron, 1982), emergency treatment (Kohen, 1986), and dying children (Gardner, 1976).

Biofeedback. Biofeedback is a pain-control method in which the patient learns how to recognize and begin to alter physiological function in a desired direction. Children learn to monitor and alter body signals such as peripheral body temperature, heart rate, alpha electroencephalogram, muscle, electromyelogram, and temporal pulse to reduce pain symptoms (Kuttner, 1997).

Allen and Shriver's (1998) randomly controlled study of 27 children ages 7 to 18 years used biofeedback treatment for these youngsters' migraine headaches. They found that although both the parent-mediated and child groups had positive responses to the treatments, the group receiving parent-mediated pain-management biofeedback evidenced significantly greater reduction in headache activity than did children who received biofeedback alone. The parent-mediated biofeedback group also demonstrated better adaptive functioning at a 3-month follow-up.

Psychotherapy

Psychotherapy interventions of insight orientation, cognitive-behavioral approaches, and family therapy use the cognitive biobehavioral principles of building the person's coping resources and strengthening his/her emotional resiliency, to influence the physiological activity that influences pain. Psychotherapy interventions are most useful when they include children and their families.

Treatment modalities found useful in the treatment of children with pain and with or without psychiatric disorders include both behavioral and cognitive therapies. Cognitive and behavioral therapies use rewards, reinforcers, desensitization, and replacement of self-defeating thoughts with positive self-talk strategies to build coping skills that help children function at their highest possible level.

Insight-oriented therapy Traditional insight-oriented psychotherapy is a useful additive when the child has pain and psychiatric symptoms. This type of therapy can help children and adolescents verbalize feelings rather than hold-in emotions - which can lead to somatization - as well as help them gain better insight into the psychological variables of their emotional distress. Family therapy focuses on promote coping factors to normalize the child's activities of daily living and promotes developmentally age-appropriate functioning. Many parents feel guilty that their child has had serious medical problems and resulting pain, and may overfunction, doing tasks or activities the child could do for him or herself. Teaching parents to allow the child to function more independently fosters self-esteem for the child, and allows the parents to care for their own needs, as they often are overburdened with medical appointments and medical care of their child.

Sometimes the child's physical complaints are psychological in nature, and he/she attempts to divert attention from parental marital conflict or other family stressors (e.g., alcoholic parent, recent death or loss). The child also may have a physical complaint to gain attention, or avoid an undesirable activity such as school or homework. Teaching parents to reinforce coping and adaptation is essential, as well as how to verbalize feelings rather than act them out.

Cognitive-behavioral therapy. Cognitive-behavioral treatments seek to modify pain behavior by modifying the social and environmental factors that influence pain expression and rehabilitation (Varni et al., 1995). Dahlquist (1999) teaches children to replace negative self-- statements about pain-such as, "This is awful, I can't handle this"-with positive self-statements such as, "I can handle this; it will be over soon; I'm strong; and if I relax I will feel better" (p. 115). Other cognitive-behavioral interventions include teaching parents to use reward programs to enhance compliance with painful procedures or tests. Sanders, Sheperd, Cleghorn, and Woolford (1994) studied 44 children 7 to 14 years old with recurrent abdominal pain. These children were randomly allocated to cognitive behavioral family intervention (CBFI) or standard pediatric care. Children who received CBFI had higher rates of complete pain elimination, lower levels of relapse at 6 and 12 month follow-up, and lower level of interference with activities.

Jay, Elliott, Woody, and Siegel (1991) developed a cognitive behavioral program for reducing children's distress. The treatment package combined filmed modeling, breathing exercises, exercise, distraction, an incentive, behavioral rehearsal, and coaching by the therapist during medical treatment. Jay and colleagues compared coping skills treatment to a nontreatment control and a diazepam administration condition. They found that the coping skills program resulted in less child distress during bone marrow aspiration compared to the controlled condition and the diazepam administration.

Evaluation of Treatment Outcomes

Careful evaluation of methods used for pain management and psychiatric treatment need to be monitored on a session-to-session basis. Indications of effective treatment include a decrease in pain quality, intensity, and duration; an increase in the child's functioning in normal activities, such as school, recreation, and social contacts; an increased ability to have a repertoire of coping strategies to self-soothe during painful times; a decrease in psychiatric symptoms such as depression or anxiety; and an improvement in the families' functioning that contributed to the child's condition.

Case Study

The multidisciplinary treatment of children in pain is very effective. The pain service found it imperative to include a psychiatric clinical nurse specialist to evaluate and treat the psychosocial aspects of children's pain.

Pain history. Katie, 16 years old, was seen as a part of a multidisciplinary pain assessment evaluation in the pain clinic in 1998. Katie had musculoskeletal pain of neck and hips after an automobile accident in 1988 when she was 6 years old and was leaving school. As she walked across the parking lot, she was struck by a station wagon. The driver did not realize he had hit her, and dragged her body for several yards. Katie remembered crying out for him to stop, but she thinks he did not stop because he did not understand English. She had a cervical fracture that resulted in three spinal fusion operations between 1991 and 1992.

The pain began immediately after she was hit by the automobile, and had varied in intensity over the last 10 years. Katie describes her pain being at its worst immediately after the accident, and during the period between 1991 and 1992, related to the numerous surgeries. She described there were no times after her injury that were completely pain free. Her pain at interview on the numerical pain intensity scale (Acute pain management guideline panel, 1992) was a 5 out of 10. The interview took place at 10 A.M. She described that her pain is usually worst in the early morning, after she awoke. She rated her morning pain as an 8. On taking her pain medication, her pain would decrease to somewhere between a 3 and 6. She reported the pain was in her neck, hips, and thighs. She reported the pain did not wake her up from sleep, but she did wake up at least once each night to use the bathroom or because she had a nightmare.

Katie was a tall girl of average weight. Her diet was good, and she generally ate three meals a day. She could walk normally. Her pain interfered with school activities; she missed 30 days of school in 1998. Her pain had not interfered with peer relations; she saw peers and went out on a regular basis. Pain symptoms did interfere with desired activities such as Rollerblading and running. She described her pain as aching and throbbing. She reported coping with pain by drawing artistic pictures, journaling, writing poems, and taking warm baths. There was no family history of pain.

Her mother was very vigilant in monitoring Katie's pain. She rearranged her work schedule to take her to medical appointments and would ask daily about Katie's pain symptoms. Katie perceived her mother as overprotective since the accident. Her mother endorsed that she was fearful that Katie would sustain another injury. During the interview, Katie was very engaged in discussing her history, she smiled occasionally, and there was no facial grimacing and no crying.

Medical history. Raynaud's phenomenon in hands and feet. Rheumatoid arthritis diagnosed in 1993. Lipoma removed in 1989 from her right leg. Cervical surgical repair in 1991 and 1992.

Medications: Previous medications include Zoloft, Amtryptyline, Anaprox, and Toridol. Current medications include Tylenol #2 qd and Tylenol #3 bid, Nortryptylline 1/4 teaspoon per day, and Ketoprophine for severe pain prn (3 times/week on average).

Previous psychiatric history. Katie saw a psychologist for 3 months following the injury. She did not remember much about the therapy, except playing with toys. Her mother reported that the therapist told her at the end of 3 months that Katie had finished therapy.

Family social history. Katie lived with her mother, 12year-old brother, and her mother's biological parents in a single-family home in an upper-middle-class neighborhood. They moved in with Katie's grandparents in 1986 when Katie's parents divorced and Katie's mother moved to Chicago from another state. Her mother reported that her ex-husband was a serious drug user, which is why she left him. The children had not seen their father in 2 years. Immediately after her mother divorced, she moved in with a boyfriend in a Southern state. She reported he was physically abusive to her and her children, and she ended the relationship within a year. Katie remembered being hit by her mother's boyfriend and being very fearful of him. Katie felt her mother defers child care decisions to her grandparents, and would like her mother to be in charge of her and her brother. Her mother worked at a health club part-time. Katie and her mother reported having good communication and a close relationship.

Family psychiatric history Her mother reported being depressed related to Katie's medical problems and suffering. Her mother was not engaged in psychiatric treatment for her depression. Katie's brother had attention deficit hyperactivity disorder and was receiving methelphenidate treatment. Katie's father was a cocaine user and dealer.

Educational history. Katie attended a public community high school as a junior. Her grades were incomplete due to missed assignments. She had missed more than 30 days of school following the injury In grade school and junior high she was an average student. Her goal was to go out of state to attend college.

Mental status exam: Katie was an attractive, Caucasian, 16-year-old girl. She was oriented times three, demonstrated good eye contact, and her thoughts were dear and goal directed. She could name the current president, do math calculations, and read well. Her speech rhythm and rate were normal. She denied feeling sad every day but said she was feeling tired of dealing with the chronic pain. She endorsed many anxiety symptoms. She became extremely fearful of riding in a car. She had a minor accident while driving and had not driven since the accident 4 months earlier. Before the car accident, she had been a very nervous driver.

She reported she had to sleep in the car in order to go places. She would wake up from sleep approximately once a week with nightmares about her childhood accident. She also endorsed having flashbacks at least once a month about the accident. She remembered she had to cut off her long hair to wear a halo brace after the surgery, which was a big loss for her. She was frightened when they had to tighten the halo brace; she remembered hearing her skull crack Katie and her mother were both in tears during this part of the interview, retelling past medical and accident events. Katie reported she was extremely hypervigilant, and often wondered if bad things would happen in her future. She felt very frustrated with the physical limitations of her medical problem. Her hobby was swimming, which was enjoyable. She had a boyfriend, who was supportive. She was currently sexually active and used birth control consistently. She denied suicidal ideation. She denied drug or alcohol use. She said when she stayed home from school, she slept and watched soap operas. Katie had no hallucinations, no delusions, no obsessions, and no compulsions. She was not suicidal or homicidal.

Formulation. Katie was a bright, engaging teenager, who appeared to be suffering from post-traumatic stress symptoms as a result of her earlier motor vehicle accident at age 6, as well as physical abuse from mother's boyfriend. She and her mother talked about the accident as if it had just occurred. It appeared they had not worked through this motor vehicle trauma to bring either of them any resolution or relief. Katie's stressful life events may have helped exacerbate her pain. Her life stressors included incomplete school assignments and potential failure of classes; past and present family problems; stress of hospitalizations, medical surgeries, and procedures; previous physical abuse; and trauma of the motor vehicle accident. Katie's life stressors are very high and may have an impact on her physical condition.

Diagnosis. See Table 3.

Plan. To begin outpatient psychotherapy treatment using various treatment modalities: * Relaxation training and distraction techniques to reduce anxiety and hypervigilance, and increase coping with pain

* Family therapy to address Katie's and her mother's anxiety regarding Katie's functioning and illness, as well as role of mother and grandparents in parenting the children * Cognitive-behavioral reexposure to decrease anxiety to riding and driving cars

* Consultation with the school to facilitate completion of courses

* Individual therapy strategies to foster self-esteem, ageappropriate decision making, and coping strategies

Outcomes. Katie attended 11 outpatient sessions once a week for 3 months. She made tremendous progress in anxiety reduction related to pain through relaxation training (deep breathing and visual imagery), distraction (journaling, painting, and spending time with friends), and insight-oriented and supportive verbal therapy. At most sessions she reported her pain was a I or 2, a drop of 3 points in her usual pain.

She did not want to discuss pain or somatic complaints; the focus of most of our sessions was on relating to peers, her boyfriend, mother, brother, and grandparents. it seemed she wanted to build social skills and family and community support, which was a very age-appropriate task. Her self-esteem improved as she caught up with schoolwork by going to summer school. She only missed a few days of summer school, and made good grades on tests and papers. Her self-esteem also improved as she joined a community teen center and made several close friends.

Family work focused on allowing her mother to work through Katie's accident and grieve over the trauma. Her mother began to develop her own social network of friends and take a more active role in parenting the children, rather than deferring the parenting role to her own parents. Katie's mother felt more empowered as a parent as a result of boundary setting within the family, and decreasing transgenerational dependence.

Katie followed up on weekly assignments of reexposure to cars and driving. The first week, she sat in the parked car in the driveway for 10 minutes, and each week progressed to riding in the car, driving around the block with her mother, to driving through the neighborhood by herself without high anxiety. Katie appeared to be able to work through her past motor vehicle trauma successfully by talking about it in individual and family therapy, and using car desensitization techniques. Katie ended treatment with resolved post-traumatic stress disorder and reduction in life stressors that may have contributed to a decreased pain response.

Conclusion

As pediatric pain management issues are becoming more attended to in our society, the child and adolescent psychiatric CNS's role in assessing and treating children with pain-related medical and psychiatric problems is a needed function. Nurses often spend more time than any other member of the healthcare team with patients with pain and, therefore, need the knowledge of pain assessment, developmental considerations, and treatment strategies. Proper pain assessment leads to accurate diagnosis and effective treatment of the diagnosis through pharmacological and mind-body treatment strategies. There is a high correlation between pain and psychiatric problems, which will be an important area for future research in the nursing literature.

Acknowledgment. The author would like to thank Janine Cataldo, PhD, RN, for advice and support in the compilation of this article.

References

Acute Pain Management Guideline Panel. (1992). Acute pain management in infants, children, and adolescents: Operative and medical procedures. Quick reference guide for clinicians (AHCPR Pub. No. 920032). Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

Allen, K.D., & Shriver, M.D. (1998). Role of parent-mediated pain behavior management strategies in biofeedback treatment of childhood migraines. Behavior Therapy, 29,477-490.

Blount, R.L., Schaen, E.R., & Cohen, L.L. (1999). Commentary: Current status and future direction in acute pediatric pain assessment and treatment. Journal of Pediatric Psychology, 24,150-152.

Chambers, C.7, Giesbrecht, K., Craig, K.D., Bennett, S.M., & Huntsman, E. (1999). A comparison of faces scales for the measurement of pediatric pain: Children's and parent's ratings. Pain, 83,25-35.

Cohen, L., Blount, R., Cohen, R., Schaen, E., & Zaff, J. (1999). Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations. Health Psychology, 18, 591-598.

Dahlquist, L.M. (1999). Pediatric pain management. New York: Kluwer Academic/Plenum.

Emslie, GJ., Rush, Aj., Weinberg, WA., Kowatch, RA., Hughes, C.W., Carmody, T., & Rintelmann, J. (1997). A double blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Archives of General Psychiatry, 54, 1031 - 1037.

Fentress, D.W., Masek, BJ., Mehegan, LE., & Bensen, H. (1986). Biofeedback and relaxation-response training in the treatment of pediatric migraine. Developmental Medicine and Child Neurology, 28,139-146.

Garber, J., Zeman, J., & Walker, L. (1990). Recurring abdominal pain in children: Psychiatric diagnosis and parental pathology. Journal of American Academy of Child and Adolescent Psychiatry, 29,684-656.

Gardner, G. (1976). Childhood death and human dignity: Hypnotherapy for David. International Journal of Clinical and Experimental Hypnosis, 24,122-139.

Good, M., & Moore, S. (1996). Clinical practice guidelines as a new source of middle range theory: Focus on acute pain. Nursing Outlook, 44, 74 - 79.

Hilgard, J., & Le Baron, S. (1982). Relief of anxiety and pain in children. Quantitative measurement and clinical observations. International Journal of Clinical and Experimental Hypnosis, 30,417-442.

Jay, SM., Elliott, C.H., Woody, ED, & Siegel, S. (1991). An investigation of cognitive behavioral therapy combined with oral valium for children undergoing painful medical procedures. Health Psychology, 10, 317-332

Joyce, B.A., Schade, J.G., & Deck, J.F (1994). Reliability and validity of preverbal pain assessment tools. Issues in Comprehensive Pediatric Nursing, 17,121-134.

Katon, W., & Schulberg, H. (1992). Epidemiology of depression in primary care. General Hospital Psychiatry,14, 14,237-247.

Kohen, D.P (1986). Applications of relaxation/mental imagery (self-- hypnosis) in pediatric emergencies. International Journal of Clinical Experimental Hypnosis, 34, 283 - 294.

Kohen, DT (1996). Relaxation/mental imagery: Self-hypnosis for childhood asthma: Behavioral outcomes in a prospective, controlled study Australian Journal of Clinical Experimental Hypnosis, 24,12-28.

Kongable, G. (2001). Psychosocial aspects of medically compromised persons. In M. Boyd (Ed.), Psychiatric nursing (pp. 894-917). Philadelphia: Lippincott.

Kuttner, L. (1997). Mind-body methods of pain management. Child and adolescent psychiatric clinics of North America: Pain Management in Children, 6, 783-815.

Leith, PJ., & Weisman, S.J. (1997). The management of painful procedures in children.Child and Adolescent Psychiatric Clinics of North America: Pain Management in Children, 6,829-842.

Luebbert, K., Dahme, B., & Jadenbring, M. (2001). The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: A meta-analytical review. Psycho-Oncology, 10, 490-502.

Management of Cancer Pain Guideline Panel. (1994). Pain control record. Clinical practice guideline: Patient guide. Managing cancer pain (AHCPR Pub. No. 94-0593). Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

Manne, S.L., Jacobsen, PB., & Redd, W.H. (1992). Assessment of acute pediatric pain: Do child self-report, parent ratings, and nurse ratings measure the same phenomenon? Pain, 48,45-52.

Mane, S., Bakeman, R, Jacobson, P, & Redd. W (1993). Children's coping during invasive medical procedures. Be Therapy, 24,143-158.

McGrath, PA. (1990). Pain in children: Nature, assessment and treatment. New York: Guilford Press.

Melzack, R. (1993). Pain: Past, present and future. Canadian Journal of Experimental Psychology, 47,615-629.

Melzack, R., & Wall, P.D. (1965). Pain mechanisms: A new theory. Science, 150,971-980.

Merren, M.D. (1998). Gabapentin for the treatment of pain and tremor: A large case series. Southern Medical Journal, 91, 739-744.

Neese, J.B. (1991). Depression in the general hospital. Nursing Clinics of North America, 26, 613-622.

Pinelli, A., Trivulzio, S., & Tomasone, L. (1997). Effects of carbamazepine treatment of pain threshold values and brain serotonin levels in rats.

Pharmacology, 54,113-117.

Ruoff, G.E. (1996). Depression in the patient with chronic pain. Journal of Family Practice,43, 25-33.

Sanders, M.R, Sheperd, R.W., Cleghorn, G., & Woolford, H. (1994). The treatment of recurrent abdominal pain in children: A controlled comparison of cognitive-behavioral family intervention and standard pediatric care. Journal of Consulting and Clinical Psychology, 62,306-314.

Savedra, M., Teller, M., & Holzemer, W. (1989). Pain location: Validity and reliability of body outline markings by hospitalized children and adolescents. Research in Nursing and Health, 12, 307-314.

Schecter, N. (1997). The status of pediatric pain control. Child and Adolescent Psychiatric Clinics of North America: Pain Management in Children, 6, 687-701.

Sifford, L.A. (1997). Psychiatric assessment of the child in pain. Child and Adolescent Psychiatric Clinics of North America: Pain Management in Children, 6, 745- 782.

Stevens, B. (1997). Pain assessment in children: Birth through adolescence. Child and Adolescent Psychiatric Clinics of North America: Pain Management in Children, 6, 725-743.

Turk, D.C., & Marcos, D.A. (1994). Assessment of chronic pain patients. Seminary in Neurology, 14, 206-212.

Turk, D.C., Meichenbaum, D., & Genest, M. (1983). Pain and behavior medicine: A cognitive-behavioral perspective. New York: Guilford Press. Varni, J.W., Blount, RL., Waldron, S.A., & Smith, A.J. (1995). Manage

ment of pain and distress. In M.C. Roberts, Ed., Handbook of pediatric psychology (2nd ed., pp. 105-123). New York: Guilford Press.

Vami, J.W., Waldron, S.A., Gragg, R.A., Rapoff, M.A., Bernstein, B.H., Lindsley, C.B., & Newcomb, M.D. (1996). Development of the Waldron/Varni pediatric pain coping inventory. Pain, 67,141 - 150.

Watson, C.PN. (1994). Antidepressant drugs as adjunctive analgesics. Journal of Pain Symptom Manager, 9,392-405.

Vanya Hamrin, MS, APRN, CS

Vanya Hamrin, MS, APRN, CS, is a Program Instructor, Yale University School of Nursing, New Haven, CT.

Author contact: vanya.hamrin@yale.edu, with a copy to the Editor: Poster@uta.edu

Copyright Nursecom, Inc. Jul-Sep 2002
Provided by ProQuest Information and Learning Company. All rights Reserved