Distraction Techniques For Children Undergoing Procedurs

Journal of Pediatric Nursing (2012) 27, 652681
Distraction Techniques for Children Undergoing Procedures:

A Critical Review of Pediatric Research
Donna Koller PhD a,, Ran D. Goldman MD b
a
Ryerson University, Toronto, Ontario, Canada

BC Children's Hospital, Vancouver, British Columbia, Canada
Key words:
Pediatrics;
Distraction;
Pain;
Nonpharmacologic pain
management;
Child life;
Medical procedures
Pediatric patients are often subjected to procedures that can cause pain and anxiety. Although
pharmacologic interventions can be used, distraction is a simple and effective technique that directs
children's attention away from noxious stimuli. However, there is a multitude of techniques and
technologies associated with distraction. Given the range of distraction techniques, the purpose of this
article was to provide a critical assessment of the evidence-based literature that can inform clinical
practice and future research. Recommendations include greater attention to child preferences and
temperament as a means of optimizing outcomes and heightening awareness around child participation
in health care decision making.
2012 Elsevier Inc. All rights reserved.
PAIN IS A complex, multidimensional and subjective

experience that consists of physiological, sensory, emotional,
cognitive, and behavioral components (Broome, Rehwaldt,
& Fogg, 1998; Lambert, 1999; Sinha, Christopher, Fenn, &
Reeves, 2006). Although the experience of pain is
unpleasant, it has an adaptive function; its presence signals
that tissue damage is about to occur, and it initiates a
protective response (Franck & Stevens, 2000; Nagasako,
Oaklander, & Dworkin, 2003). However, the prolonged
exposure to pain can have deleterious effects.
The study of pain and anxiety in infants, preschool
children, children, and adolescents has revealed that the
nervous system is vulnerable to noxious stimuli during
development. Not only does pain have a negative impact on
neurological development, but children whose pain has not
been adequately treated in infancy or early childhood
reported lower pain thresholds as adolescents and adults
(Ruda, Ling, Hohmann, Peng, & Tachibana, 2000). Pain is
also associated with heightened levels of distress and anxiety
during procedures, which can result in negative long-term
emotional outcomes (Blount, Piira, Cohen, & Cheng, 2006;
Corresponding author: Donna Koller, PhD.

E-mail address: dkoller@ryerson.ca (D. Koller).
0882-5963/$ see front matter 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pedn.2011.08.001
Brewer, Syblik, Tietjens, & Vacik, 2006; Howard, 2003;

Ruda et al., 2000).
In particular, pediatric patients in the emergency department (ED) are often subjected to unexpected procedures that
cause pain and increased anxiety and distress (Blount et al.,
2006). Intravenous (IV) insertions, intramuscular or subcutaneous injections, central venous port access, and urethral or
angiocatheter insertions are routine ED procedures. The use
of topical creams, such as lidocaine and prilocaine (EMLA),
to provide topical anesthesia has been shown to reduce the
pain associated with these procedures (Skarbek-Borowska,
Becker, Lovgren, Bates, & Minugh, 2006). However, these
creams can take up to 1 hour to provide sufficient epidermal
and dermal anesthesia (Blount et al., 2006).
Pediatricians and emergency physicians are often hesitant
to administer analgesics in the ED (Mahan & Strelecky,
1991; Selbst & Clark, 1990). For instance, MacLean,
Obispo, and Young (2007) found that few to no pediatric
patients who presented at an urban ED received pharmacologic pain management for procedures such as venipunctures, IV catheter placement, and finger pokes (p. 87).
Even when anesthetics are administered, pediatric patients
continue to report procedural-related distress and pain
(Dahlquist, Pendley, Landthrip, Jones, & Steuber, 2002).
Although limited pharmacologic interventions reduce the
Distraction Techniques for Children Undergoing Procedures

likelihood of toxicity and can increase the speed at which
health care professionals can perform procedures, pediatric
patients are often left in pain, feeling anxious and distressed.
Distraction is a commonly used nonpharmacologic pain
management technique used by both health care professionals and parents to attenuate procedural pain and
distress. Distraction operates on the assumption that by
shifting a child's focus to something engaging and attractive,
his or her capacity to attend to painful stimuli is hindered,
thereby reducing pain, distress, and anxiety (Kleiber &
McCarthy, 2006; Lambert, 1999). In pediatrics, distraction is
often defined as a strategywhether cognitive or behavioral
that draws a child's attention away from noxious pain
stimuli (Sander, Eshelman, Steele, & Guzzetta, 2002).
Kleiber and Harper (1999) draw further distinctions and
define distraction as a cognitive coping strategy that
passively redirects the subject's attention or actively involves
the subject with a task.
Despite its widespread use, there is no universally
accepted theory to explain the function of distraction
(DeMore & Cohen, 2005, p. 282). However, a greater
understanding of exemplary practices concerning nonpharmacologic pain management can assist health care professionals in offering coping strategies to pediatric patients
and their families. Given the range of distraction techniques
within pediatrics, the purpose of this article is to provide
a critical assessment of the evidence-based literature that
can inform clinical practice and future research. Because
developmental considerations are important in this literature,
mesh terms from PubMed are applied here. Hence, the use of
the term infant will coincide with age 02 years; preschool
children, 25 years; children, 612 years; and adolescents,
1319 years. The studies reviewed here include participants
from 1 to 19 years of age.
Research Methods
An exhaustive search of the literature was conducted on
(a) PsycINFO, which indexes the literature from psychology
and related disciplines such as medicine, psychiatry, nursing,
sociology, and education; (b) MEDLINE, which focuses on
biomedical literature; and (c) CINAHL, the Cumulative
Index to Nursing and Allied Health Literature, which covers
literature relating to nursing and allied health professions. A
variety of keywords such as pediatrics, paediatrics, child
(children), adol (adolescents), pain, anxiety, fear, distraction, relaxation, virtual reality, guided imagery, television,
coping, strategies, and music were used to conduct the
search. Keyword combinations included coping and strategies, pediatrics and pain, distraction and coping, anxiety,
coping, and pediatrics. A variety of these keyword
combinations were searched on two occasions within each
of the databases over an 18-month period. In both cases,
searches were conducted at a major pediatric teaching facility
653
under the direction of a librarian with a master's in
information science. The librarian had an understanding of
the types of materials and subjects covered in the databases
and an awareness of the advantages/disadvantages of
controlled vocabulary searches and possible spelling differences in terminology (e.g., British vs. American). All search
results were limited to original pediatric studies published
between 1990 and December 2009. The final search was
completed in December 2009.
Searches revealed approximately 150 citations, which
included original articles from empirical research, review
articles, and non-empirical-based literature (e.g., anecdotal
reports). The results were sorted to exclude duplicates (e.g.,
multiple publications of same study) and nonempirical
research. Review articles were perused for additional
citations from their reference lists, and an additional 3
articles were ordered through interlibrary loan, as they were
not readily available. In total, 46 original study articles from
peer-reviewed journals were retrieved.
Selection criteria were determined by the scoring of two
independent raters using the Quality of Study Rating Form
(Gibbs, 1989). Articles were assessed and evaluated on a
number of issues, including identification of theoretical
framework, statement of purpose and research questions,
recruitment procedures, sample sizes, methods, effect sizes,
and validity of standardized measures. Each area received a
corresponding score of either 0 (omission of area) or the
number allotted to the category. Articles that received a
rating of at least 60 of 100 points were selected for inclusion
in this review. For those articles that scored between 55 and
65 points, a third rater confirmed inclusion or exclusion.
Forty-six research articles met the selection criteria.
For each study, the content and rating were recorded using
a Microsoft Excel (2003) spreadsheet. Studies for this review
predominantly used quantitative methods through experimental designs (randomized controlled, quasi-experimental,
and multiple case study), whereas only two studies used
mixed methods, which included interviews and narrative
accounts. Methods of data collection included self-rating
scales, observer ratings, and parent reports. In particular,
several measures of pain and distress were administered
through pain assessment scales, physiological indices, and
behavioral distress assessments. Review articles addressed
specific forms of distraction in the context of particular
procedures. Accordingly, the studies selected here investigated the effectiveness of various distraction modalities on
pediatric patients' pain and anxiety. Modalities include
auditory, visual, bimodal, and interactive techniques.
Because of the number of techniques cited in the
literature, evidence is examined and organized under main
categories of active and passive forms of distraction.
Active forms of distraction include interactive toys or
electronic games, virtual reality (VR), controlled breathing, and guided imagery/relaxation. In the case of active
distraction, participants are typically coached by an adult
to engage in the activity. Passive forms of distraction
Study no.
654
Table 1
Active Distraction
Reference
Study Focus
1. Interactive toys (electronic and VGs)

Effect of three different V-tech
1
Data from
electronic toys (V-tech
Dahlquist,
Industries, Wheeling, IL) on
Busby, et al.
pain management and
(2002)
behavioral distress in children
undergoing repeated needle
sticks
Sample
Findings
6 preschool children and

children (age range = 2
8 years old) with chronic
illness and their parents
4 male and 2 female
Experimental design
9 distraction sessions were
provided in which parents
were coached to use
distraction techniques
Participants behavioral distress
measured by the Observation
Scale of Behavioral Distress,
observer ratings of participant
distress measured via the
VAS, and parent self-reports
were collected
During the distraction

treatment program, 5 of 6
participants had a clinically
significant reduction in
behavioral distress
Clinically significant
improvements in parental
reports of participant distress,
nurse estimates of
participants' cooperation, and
parents' self-report of feeling
upset during the needle sticks
procedure
Participants receiving the
distraction intervention were
rated as significantly less
anxious by nurses and
parents, paired sample t test,
t(28) = 4.96, p b .01;
t(28) = 2.52, p = .02
Interactive games are
effective in decreasing
anxiety and distress of
children, aged 25 years,
undergoing invasive medical
procedures
When older children, aged
1014 years, wore the
HMD helmet, they
demonstrated significantly
higher pain tolerance
(ANOVA, M = 70.08,
SD = 71.22) than younger
participants, aged 69 years
(M = 31.74, SD = 40.36;
t = 2.193, p b .05)
Both distraction conditions
resulted in improved pain
tolerance when compared
with participants using no
games
Data from
Dahlquist,
Pendley, et al.
(2002)
Effect of an electronic toy as a

distraction strategy to reduce
anxiety in children undergoing
intramuscular injections and
subcutaneous port access
29 preschool children (age

range = 25 years) from
the outpatient hematology
oncology clinic
22 male and 7 female
2-Group repeated-measures
design
Random assignment to
distraction condition (Texas
Instruments [Dallas, TX]
Touch and Discover
electronic toy) or wait-list
control condition
Observer ratings collected
with the Observation Scale of
Behavioral Distress
Data from
Dahlquist et al.
(2009)
Effect of an HMD helmet in VG

distraction for children
experiencing cold processor
pain
41 children and adolescents

(age range = 614 years)
Experimental stratified
random sampling design
All participants underwent 1
or 2 baseline cold processor
trials followed by 2
distraction trials (played the
same VG with and without
the helmet in
counterbalanced order)
Pain threshold and pain
tolerance were measured for
each cold processor trial
D. Koller, R.D. Goldman
Method
2. VR
5
Data from Patel

et al. (2006)
Effect of a handheld interactive

VG on reducing preoperative
distress

years) undergoing outpatient
surgery
Randomized, prospective study

Random assignment to 1 of
3 groups;
1 - PP
2 - PP + oral midazolam
3 - PP + a handheld VG
Observer ratings on
participants' anxiety collected
via the Modified Yale
Preoperative Anxiety Scale and
the Posthospitalization
Behavior Questionnaire
The group that received an

interactive handheld VG and
had PP prior to surgery
experienced a statistically
significant 63% decrease in
anxiety. In contrast, there was
a 28% decrease for the group
provided only with PP and
26% for the group which had
both PP + oral midazolam
(chi-square test, 2 = 9.26,
df = 2, p = .01)
Patients who were actively
engaged in playing with a VG
had statistically less distress
at induction of anesthesia
compared with children who
only had PP (KruskalWallis
test, p = .04)
Statistically significant
increase in anxiety in groups
oral midazolam and PP at
induction of anesthesia
compared with baseline
(Wilcoxon signed rank test,
p b .01), but not in the
handheld VG group
A handheld VG is useful in
reducing preoperative distress
Data from
Gershon et al.
(2004)
Effect of VR as a distraction to
decrease anxiety and pain
associated with an invasive
medical procedure in cancer
patients

with cancer (age range =
719 years) undergoing IV
port access
Pilot study: randomized

control trial design
Random assignment to one of
three groups:
1 - VR distraction
2 - a non-VR (interactive
game) distraction
3 - Treatment with no
distraction
Participants' self-reports were
collected, physiological
responses (pulse rate) were
measured, and parent
and nurse observer ratings
During VR, participants had

significantly lower pulse
rates, indicating a decrease in
pain and distress during
invasive medical procedures
(p b .05). Analysis of
variance tests were used to
examine treatment efficacy
between the 3 conditions with
post hoc analysis based on
omnibus results
No statistically significant
difference in anxiety between
non-VR and no-distraction
655
(continued on next page)
656
Table 1 (continued)
Study no.
Reference
Study Focus
Sample
Data from Gold

et al. (2006)
Effect of VR as a pain
distraction for pediatric IV
placement
20 children (age range = 812

years) requiring IV placement
for a MRI/CT scan
Data from
Nilsson et al.
(2009)
Effects of using nonimmersive

VR during a needle-related
procedure on reported pain or
distress of children and
adolescents in an oncology unit
42 preschool children,
children, and adolescents
at the Queen Silvia
Children's hospital
Method
Findings
recorded throughout the

procedure. Scales included
the VAS and the Children's
Hospital of Eastern
Ontario Scale
Experimental stratified
random sampling design
Random assignment to 1 of 2
conditions: VR distraction
using Street Luge, by Fifth
Dimension Technologies
(Irvine, CA), presented via a
head-mounted display, or a
control condition with no
distraction
Self-report questionnaires
completed by participants, their
parents, and nurses via the
VASs, Wong-Baker FACES
Pain Rating Scale, the
Childhood Anxiety Sensitive
Index, the Child Simulator
Sickness Questionnaire, and
the Child presence
questionnaire. Demographic
information and satisfaction
scores were also collected
Mixed-method design
21 participants assigned to
an intervention group
(nonimmersive VR); another
21 patients to a control group
Before, during, and after the
procedures, participants
reported on pain and distress
using the CAS and the FAS.
Heart rate was measured, and
observational pain scores were
obtained via the FLACC scale
Semistructured qualitative
interviews were conducted at
the end
conditions
VR acts as a useful distracter
during invasive medical
procedures
Participants receiving VR
distraction were significantly
more satisfied with their pain
management than
participants in the control
condition, Pearson's r,
F(1, 18) = 12.17, p b .01)
VR pain distraction was
positively endorsed by all
participants as an effective
strategy for decreasing pain
and distress during acute
medical interventions
The self-reported pain

intensity and distress scales
demonstrated no significant
difference between the
groups prior to, during, or
after the intervention
Participants undergoing a
minor procedure found
nonimmersive VR to be an
enjoyable experience; yet
their reported pain intensity
did not decrease
Data from
Sander et al.
(2002)
Effect of VR glasses as a
distraction measure to reduce
pain in adolescents undergoing
lumbar punctures (LPs)

with cancer undergoing LPs
Data from
Schneider and
Workman
(2000)
Effect of using VR as a
distraction intervention for
children receiving outpatient
chemotherapy

(age rage = 1017 years)
undergoing treatment for a
malignant disease
6 male and 5 female
10
Data from
Sharar et al.
(2007)
Effectiveness of VR as a
distraction technique in children
undergoing postburn physical
therapy
88 children, adolescents,
adults, and seniors (age
range = 665 years) affected
by burn injuries
75% of participants were
aged 618 years
Prospective, randomized,
controlled, within-subject
design
Participants received both
conditions: standard
analgesic (opioid and/or
benzodiazepine) care and
standard analgesic care +
immersive VR distraction
Participants self-report
measures of subjective
pain were collected via the
100-mm GRS
11
Data from
Wolitzky et al.
(2005)
Effect of VR as a distraction
strategy to decrease distress
during port access procedure

Experimental randomized
Random assignment to either
an immersive VR
VAS pain scores tended to be

lower in the VR group as
compared with the control
group, indicating less pain
77% of participants in the VR
group said the VR glasses
helped to distract them during
the LP
VR glasses are effective in
reducing the pain associated
with LPs
9 of 11 participants indicated
that the chemotherapy
treatment with VR was better
than previous chemotherapy
treatments
All participants wanted to use
VR again
VR is an effective distraction
strategy in enhancing positive
clinical outcomes
Compared with the standard
care condition, patients under
VR distraction reported
statistically significant lower
pain ratings for intense pain,
pain unpleasantness, and time
spent thinking about pain
(SAS d, GRS, 54.2 3.1 vs.
43.5 3.5, p = .003; GRS,
41.0 3.6 vs. 30.3 3.0,
p = .01; GRS, 47.1 3.5 vs.
29.5 3.0, p b .001).
Age did not affect outcome of
pain measures
VR distraction provides a
significant amount of pain
relief to patients undergoing
postburn physical therapy
Participants in the VR
condition experienced
significantly less pain,
MANOVA, t(18) = 4.13,
657
control group design
17 participants randomly
assigned to the VR group
(wore VR glasses and
watched a video) and 13
adolescents in the control
group (no VR glasses)
All participants rated their
pain after LP using a VAS
and were interviewed to
evaluate their experience
Pilot study
Participants were asked to use
the VR equipment during
their chemotherapy treatment
After treatment, participants
completed the evaluation of
VR intervention form
658
Table 1 (continued)
Study no.
Reference
3. Controlled breathing
12
Data from
French et al.
(1994)
Data from Lal

et al. (2001)
Sample
Effect of an active distraction

technique, blowing out air
repeatedly, on reducing pain
during immunization
149 preschool children

and children (age range =
47 years) having preschool
diphtheria, pertussis, and
tetanus immunization
71 male and 79 female (this
does not add up to 149, but
these are the numbers used in
the article)
Comparison of eutectic
mixture, a type of local
anesthetic (EMLA) cream,
versus placebo in children
receiving distraction therapy for
venipuncture
48 years) attending for
venipuncture
Gender of participants not
specified
Method
Findings
environment during the

procedure or a non-VR
control condition
Participants' distress was
assessed through a selfratings scale (the VAS),
objective physiological data,
and behavioral measures
(Children's Hospital of
Eastern Ontario Pain Scale)
p b .01, and had significantly

lower pulse rates during the
procedure, MANOVA,
t(18) = 2.14, p b .05, than the
control group
VR was effective in reducing
participant distress and
anxiety on all measures
Randomized, unblinded,
controlled study design
Participants were divided into
4 groups. Two groups were
created for the experimental
group;
1a - Taught to blow out
when they received a
shot in addition to
being taught the VAS
2a - Taught to blow out but
not taught VAS. The
control group also had
two groups
1b - Taught to blow out during
a shot; however, they
were taught the VAS
2b - Not taught either
technique.
Participant self-reports and
parent and nurse ratings on
participants' pain (VAS) were
collected. Observer ratings on
participants' pain (OSBD) were
also collected
Prospective, randomized,
double-blind, placebocontrolled, clinical trial design
All participants were given
distraction therapy by a
play specialist prior to
Participants who were under

the experimental conditions,
i.e., taught to blow out air
during the procedure, had
significantly fewer pain
behaviors (MannWhitney
U test, n = 70 vs. n = 77,
p b .04), and reported
significantly less pain
(MannWhitney U test,
n = 36 vs. n = 39, p = .06)
than the control conditions
Simple distraction techniques,
like blowing out air
repeatedly, can be effective in
helping preschool children
and children between the ages
of 4 and 7 years cope with
immunization
difference in pain scores
between the treatment and
control groups were found
Low pain scores were
obtained in both groups,
13
Study Focus
Data from
Manne et al.
(1990)
The use of party blowers

combined with parental
coaching and positive sticker
reinforcements to help reduce
pain and stress during
venipuncture for invasive
cancer treatment

years) requiring physical
restraint to complete
venipuncture
15
Data from
Peretz and
Gluck (1999)
Effect of an active distraction

technique, repeated breathing
and blowing out of air, on the
37 years)
Half the participants were
indicating the effectiveness of

distraction therapy
Significant reduction in
participants' distress, parental
ratings of their child's pain,
and parental anxiety occurred
in the behavioral intervention
group over the course of 3
intervention trials.
Correlations among the 4
measures of participant
distress were all significant,
with coefficients ranging
from .39 (Pearson's r,
p b .001; parents rated
distress and child self-report)
to .80 (Pearson's r, p b .01;
observed distress and nurserated distress)
Participants' perception of
pain was not significantly
affected by the behavioral
intervention
The significant reduction in
participant's distress, parental
ratings of their child's
distress, and parental anxiety
demonstrates the
effectiveness of distraction
interventions and parental
involvement for patients
undergoing repeated invasive
cancer treatments
More participants in the
intervention group than in the
control group significantly
659
14
and during the venipuncture

17 participants were
assigned to the treatment
group (EMLA) and 10
participants assigned to
the control condition
(placebo cream)
Objective pain scores were
collected at the end of the
procedure
Experimental alternate
assignment design
13 participants in the
behavioral intervention group
(instruction in attention
distraction, use of party
blowers, paced breathing, and
positive reinforcement) and
10 participants in the
attention control group
(parents encouraged to use
their own ideas to divert
child's attention during
treatment)
Participant distress (observed,
self-reported, parent rated,
and nurse rated), parent
distress, and nurse distress
collected via the Procedure
Behavior Rating Scale, the
Wong-Baker FACES Pain
Rating Scale, and the VAS
660
Table 1 (continued)
Study no.
Reference
4. Guided imagery and relaxation

16
Data from Ball
et al. (2003)
17
Data from
Broome et al.
(1994)
Study Focus
Sample
Method
Findings

specified
assigned to the intervention

group (asked to breathe
deeply before and during
administration of the
injection and to blow air out)
or the control group (no
repeated breathing and air
blowing)
Measures not specified
expressed their wish to have

the same technique used
during the second visit
(p = .033)
Participants in the
intervention group
demonstrated less hand and
torso movements and less
eyebrow bulging and
expressed less pain than the
control group
Effect of guided imagery and

relaxation for the treatment of
RAP in children
with RAP
Gender of participants
not specified
Participants experienced a
statistically significant 67%
decrease in pain during the
first 2 months of therapy
(chi-square for trend,
p b .00l)
The use of relaxation along
with guided imagery is an
effective and safe treatment
for childhood RAP
Effect of distraction and

imagery with children during
painful procedures
children and adolescents
(age range = 315 years) with
acute lymphocytic leukemia
and receiving LPs
Pilot study: randomized

an intervention group or a
wait-list control group
Participants received
relaxation training and
guided imagery during 4
weekly 50-minute sessions
Pain diaries and the WongBaker FACES Pain Rating
Scale were completed by
participants and their parents
at 0, 1, and 2 months
Multiple case study design
Baseline data obtained at the
first 3 visits prior to the
introduction of relaxation,
imagery, and distraction
exercises
Self-ratings of participant's
fear and pain and parent
anxiety were collected,
videotaped observations of
the participants' and parents'
behavior were taken, and
child pain ratings were
obtained at all 3 visits. Scales
used included the Child
Medical Fear Scale, the
Participant's behavioral
responses to the procedure
varied considerably, but their
fear scores were stable and
their reports of pain
significantly decreased over
time (t = 3.21, p = .008)
Guided imagery can be used
as a means of reducing
pediatric patients' pain and
anxiety and parental anxiety
and distress
pain behavior and facial display

of children receiving local
anesthesia injections prior to
dental treatment
Data from Huth

et al. (2004)
Effect of imagery, in addition to

routine analgesics, in reducing
tonsillectomy and/or
adenoidectomy pain and
anxiety after AS and at home
73 children (age range =

712 years) scheduled for
tonsillectomy or
adenoidectomy
19
Data from Huth

et al. (2009)
Effectiveness of a guided
imagery audio CD in reducing
postoperative pain, increasing
relaxation, and stimulating
imagery in children

712 years) hospitalized over
a 7-month period for a variety
of surgeries
8 male and 9 female
Those who had imagery

reported significantly less
pain shortly after AS than the
control group (MANCOVA
at T2, F[3.66] = 3.02, p = .04)
Health care providers can use
imagery to reduce
postoperative pain following
tonsillectomy and/or
adenoidectomy
18
Observation of Behavioral
Distress Scale, the BakerWong FACES Scale, the
Spielberger State/Trait
Anxiety Scale, and the Parent
Behavior Tool
Unblinded experimental
study
36 participants assigned to
the treatment group: watched
a videotape on the use of
imagery and listened to a
30-minute audiotape of
imagery 1 week prior to
surgery; they listened to only
the audiotape 14 hours after
surgery and 2227 hours
after discharge from AS
37 participants assigned to the
attention control group: they
received standard care
Participant self-report
measures on pain and distress
were collected via the Oucher
Scale and the FAS. Diary
entries were also collected
and analyzed
Cross-sectional pre/posttest
design
Compared pain and relaxation
scores before and after
listening to the CD titled
Magic Island: Relaxation
for Kids
Demographic information
and participant self-reports,
via the Oucher Scale, were
collected. Interviews were
conducted with participants
Listening to the CD
stimulated imagination of 14
(82%) of the 17 participants
Participants reported a
significantly lower pain score
pre- to postintervention.
Mean pain score before the
CD was 4.31 (SE = 0.61),
whereas it was 2.75 after the
CD (SE = 0.49, paired t test,
t[15] = 3.49, p = .0033).
However, although pain
ratings decreased, no
statistically significant
increase in relaxation was
found
Guided imagery proved
661
662
Table 1 (continued)
Study no.
Reference
Study Focus
Sample
Data from
Lambert (1996)
Effect of hypnosis/guided
imagery on the postoperative
course of pediatric surgical
patients

scheduled for elective surgery
21
Data from
Pederson
(1995)
Effect of guided imagery on

children's pain and anxiety
during cardiac catheterization

scheduled for cardiac
catheterization
22
Data from
Smart (1997)
Effect of music and guided

imagery in relaxing children
and reducing the use of
sedatives before MRI

8 years) scheduled for an MRI
Experimental 2-group,
pre/posttest design
2 groups; the experimental
group was taught guided
imagery by the investigator,
and the control group spent
time with a research assistant
Participant self-report
measures on pain and distress
were collected via the
Numeric Pain Scale and the
Spielberger State Anxiety
Inventory
3 groups:
1 - Control group
2 - Presence group
3 - Imagery group
Physiological, psychological,
and behavioral data were
used to rate pain and anxiety
during cardiac catheterization
2-Group experimental design
the treatment group (listened
to the Magic Island tape using
headphones) or the control
Findings
effective in reducing pain
when the child was in a
highly anxious state, but
results were not always
sustained after the participant
returned home (effect was
short-lived)
Relaxation may not be a
necessary component for pain
reduction, but stimulating
imaginations might be
beneficial
Significantly lower
postoperative pain ratings for
participants in the guided
imagery group (paired t test,
mean 3.9, p b .01)
State anxiety was reduced for
the experimental group and
increased postoperatively for
the control group
Positive effects found with
hypnosis/guided imagery for
the pediatric surgical patient
Participants in the imagery

condition displayed fewer
distress behaviors during
cardiac catheterization
Participants in the presence
condition reported the lowest
levels of pain
7 of 10 participants who
listened to the music and
imagery tape remained still
for the MRI and did not
require sedation.
20
Method
Data from
Weydert et al.
(2006)
Effect of guided imagery as a

treatment for RAP in children
Only 2 of the 10 participants

who did not hear the tape
remained calm and did not
need sedation
Guided imagery resulted in

statistically significant
decreases in the number of
missed activities due to pain
and the number of days in
pain within the first month
(67% vs. 21%, p = .05; 85%
vs. 15%, p b .01) and second
month (82% vs. 45%,
p b .01; 95% vs. 77%,
p = .05). All analyses were
compared using the Student's
t test or chi-square
statistical test
Guided imagery can help
improve social functioning
and effects can be sustained
over the long term
23
group (listened to no music

using headphones)
Participants who were unable
to remain still during the
testing were given sedation
according to hospital protocol
Pretest questionnaire and mini
interviews were conducted
with participants
Participants were
randomized to learn either
breathing exercises alone or
guided imagery with
progressive muscle relaxation
Using a daily diary,
participants reported the
numbers of days with pain,
pain intensity, and missed
activities due to abdominal
pain
Depression, anxiety, and
somatization measured in
both participants and parents
at baseline using a variety of
rating scales (Bowel
Symptom Questionnaire,
Child Depression Inventory,
Multidimensional Anxiety
Scale for Children, EAS
Temperament Scale, Child
Somatization Scale,
Symptoms Checklist-90, and
the Parent Bonding
Instrument)
Note: HMD = head-mounted display; VG = video game; PP = parental presence; CT = computed tomography scan; VAS = visual analog scale; MANOVA = multivariate analysis of variance; RAP = recurrent
abdominal pain; AS = ambulatory surgery.
663
Study no.
664
Table 2
Passive Distraction
Reference
1. Auditory distraction: music

1
Data from Aitken
et al. (2002)
Study Focus
Method
Effect of audio distraction

in reducing pain, anxiety,
and disruptive behavior
during pediatric dental
procedures

children (age range =
46 years)
specified
Experimental design
Participants were assigned to 1
of 3 groups:
1 - Upbeat music
2 - Relaxing music
3 - No music
Parent-reported anxiety measures via
the Modified Corah Anxiety Scale;
self-reported anxiety measured via
the Venham picture scale; heart rate;
behavior measured via the Behavior
Rating Scale; and pain measured
using the VAS
Double-blind experimental
stratified random sampling design
The 3 age groups were 46 years,
711 years, and 1216 years;
60 children were assigned to
each group
3 groups were assigned:
1 - Received lidocaine-prilocaine
emulsion (EMLA, Astra
Zeneca, Wilmington, DE).
2 - Received a placebo cream that
was indistinguishable in
appearance from EMLA
3 - Received music
(contemporary, upbeat music)
via earphones.
Participant self-reports were
collected via the FPS and
VAT, and global
observation ratings were collected
Experimental design
Sound (music and random noise)
was used in combination with EDA
Pain was assessed using the Color
Scale and the Sound, Eye, and
Motor Scale
Behavior was assessed by the
North Carolina Behavior
Data from Arts

et al. (1994)
Effect of a local anesthetic

cream (EMLA) and music
distraction in reducing or
preventing pain from
needle puncture (IV
cannulation) in children

undergoing surgery under
general anesthesia via IV
cannulation
Data from
Baghdadi (2000)
Effect of music and white

noise in the management of
sensitive children treated
using EDA for restorative care

912 years) with low
pain tolerance during
operative procedures
under electronic
anesthesia alone
specified
Findings
differences were found among the
3 groups across any variables
Audio distraction was not an
effective means of reducing
anxiety, pain, or uncooperative
behavior during pediatric
restorative dental procedures
Participants in the EMLA

condition reported significantly
less pain on all 3 pain scales than
those in the placebo or distraction
conditions (FPS, 2 = 2.62 vs.
2.58 vs. 1.42, p = .001; VAT,
2 = 4.55 vs. 4.33 vs. 2.18,
p b .001; GBAS, 2 = 1.23 vs.
1.10 vs. 0.58, p = .003)
Participants, 46 years old,
regardless of intervention, reported
significantly more pain than children
and adolescents more than 6 years
old on all 3 pain measures (FPS, 2 =
2.85, p b .001; VAT, 2 = 5.11, p b
.001; GBAS, 2 = 1.17, p = .002)
Gender, experience with
venipuncture, and level of child's
anxiety had no bearing on the results
The use of EDA combined with
audio diversion resulted in
significant improvements in
behavior and comfort during dental
procedures (t test)
The music promoted relaxation,
whereas noise in combination with
electronic signals suppressed pain
Sample
Data from Bo and

Callaghan (2000)
Effect of NNS, MT, and

combined NNS and MT
versus no intervention on
heart rate, transcutaneous
oxygen levels, and pain
behavior on neonates in
intensive care units having
blood taken by a heel-stick
procedure
27 infants (age range =

3041 weeks) in the
special care baby unit of a
government-funded
general hospital in
Hong Kong
Within-subjects, counterbalancing,
repeated-measures design
All patients received NNS, MT,
combined NNS and MT, and no
intervention in a random order each
time after a heel-stick procedure
Observer ratings were collected to
assess infant's pain via the Neonatal
Infant Pain Scale and the VAS.
Heart rate and transcutaneous
oxygen levels were also collected
Data from Gousie

(2001)
Effect of MT in reducing
pediatric pain perception
during injections

210 years) from the Rap
Clinic at the University
Hospital of Cleveland
19 female and 16 male
Experimental randomized control

trial design
19 participants in experimental
group (MT)
16 participants in control group
(no MT)
Observational behavioral
assessments collected via the
Behavioral Assessment Dialysis
Rating Form
Data from Jeffs

(2007)
Effect of self-selected
distraction on pain and
anxiety during allergy
testing in adolescents
32 children and
adolescents (age range =
1117 years) who were
scheduled for food and/or
environmental allergy
skin testing
Randomized, unblind experimental

design
3 conditions:
1 - Self-selected distraction
(music, teen books, movies,
music videos, sports
programs, cartoons)
2 - Investigator-selected
distraction (watched nursing
recruitment video)
3 - Usual care
Audio analgesia and EDA may be

used successfully in combination to
reduce pain and enhance relaxation
All 3 interventions significantly
reduced infants' heart rate (Wilks'
= 0.647; F[2, 27] = 18.93; 2 =
0.35; p b .0001), improved their
transcutaneous oxygen levels
(Wilks' = 0.481; F[2, 27] =
37.42; 2 = 0.51; p b .0001), and
reduced their pain behaviors
(Wilks' = 0.312; F[2, 27] =
76.42; 2 = 0.68; p = .0001)
Health professionals using NNS +
MT when doing heel sticks can
improve the transcutaneous oxygen
levels of infants and reduce their
pain and pain behaviors
Using MT alone can help decrease
the heart rate of infants during heelstick procedures
Experimental group demonstrated a
decrease in pain perception and less
behavioral distress during the
injections
Music is correlated with improved
interactions between preschool
children and children, parents,
and health care professionals in
addition to facilitating greater pain
management and quicker recovery
times
difference was found in pain
ratings among the 3 groups
Lower anxiety and greater
engagement with distraction was
associated with less pain
Greater engagement with
distraction associated with less
anxiety
665
Rating Scale
666
Table 2 (continued)
Study no.
Reference
Study Focus
Sample
Data from Joyce

et al. (2001)
Effect of music and eutectic

mixture of local anesthetics
(EMLA) on pain responses
of neonates undergoing
circumcision
23 infants (age range =

less than 24 hours)
All participants were
male
Data from Malone

(1996)
Effect of live music on the

behavioral distress and
anxiety levels of pediatric
patients receiving needle
insertions
40 infants, preschool
children, and children
Data from Megel

et al. (1998)
Effect of audio-taped
lullabies on physiological
and behavioral distress and
perceived pain among
children during routine
immunization
99 healthy preschool
children and children
attending an
immunization clinic
Participants' pain was measured by

the adolescent pediatric pain tool
and the Wong-Baker FACES pain
rating scale
Randomized, double-blind
experimental design
Infants received EMLA or placebo
cream; applied at least 1 hour prior
to procedure. The audio stimulus
(music by Baby go to Sleep) played
just prior to the procedure
Pain intensity was measured based
on observational responses using
the Riley Infant Pain Scales. Heart
rate, respiratory rate, oxygen
saturation levels, salivary cortisol
levels, and length of cry were also
collected
Experimental design
20 patients in the experimental
condition received live music
during a variety of needle
insertions
20 patients in the control condition
received no music
Observer ratings of behavioral
distress collected via an adapted
version of the Predominant
Behaviors Category List and
another behavioral distress scale
(name of scale not specified)
trial design
Random assignment to either an
experimental group receiving musical
intervention during procedure, or
control group with no music
Behavioral distress was measured
via the OSBD. Pain perception was
measured via the Oucher Scale and
physiological variables (heart rate,
blood pressure) were also collected
Findings
Pain ratings were significantly

lower for infants in the music
condition by the end of procedure
(F = 5.53, df = 1/21, p = .03)
Music is an effective distraction
strategy in reducing pain for infants
undergoing circumcision
The experimental group exhibited

significantly less behavioral
distress than the control group
(ANOVA, F = 9.6, p b .05)
Music can be an effective
distraction technique in helping
children cope during painful
procedures
differences were found between
experimental and control groups on
heart rate, blood pressure, or pain
perception scores
There was a significant difference
in the OSBD scores between boys
and girls. Boys showed significantly
more distress behaviors during
immunization (KruskalWallis, z =
1.97, p = .048)
Method
Data from Tanabe

et al. (2002)
Effect of nursing
interventions in decreasing
pain for children with minor
musculoskeletal trauma and
moderate pain
who were accompanied
by a parent or legal
guardian and had minor
extremity trauma (distal
to the elbow and knee) in
the ED
specified
11
Data from
Whitehead-Pleaux
et al. (2006)
Effect of MT on pain and

anxiety in pediatric burn
patients during a dressing
change
14 children and
616 years) from the
Shriners Burns HospitalBoston
5 male and 9 female
12
Data from
Whitehead-Pleaux
et al. (2007)
Effect of MT on pain and

anxiety in pediatric burns
patients during procedures
9 children and
716 years) from Shriners
Burns HospitalBoston
3 male and 6 female
Experimental systematic
assignment design
Participants were assigned to 1 of 3
intervention groups and monitored
for 60 minutes:
1 - Standard care (ice, elevation,
immobilization)
2 - Standard care and ibuprofen
3 - Standard care and distraction
(music or toys)
Interviews were conducted; child
self-reports on pain were collected
via the Wong-Baker FACES Scale
and the Numeric Rating Scale, and
patient satisfaction questionnaires
administered
trial design
Patients were randomly assigned to
1 of 2 groups: experimental group
(live music) or control group
(verbal interaction)
Psychological and behavioral data
were assessed through the WongBaker FACES Pain Rating Scale,
the Fear Thermometer, and the
Nursing Assessment Pain Index.
Physiological data including heart
rate, and respiration rates were
also collected
Mixed-method design
Each participant received MT
during nursing procedures
Interviews were conducted;
participant self-reports of pain and
anxiety were collected via the
Wong-Baker FACES Scale and the
Fear Thermometer; behavioral
distress was collected by nurses via
the Nursing Assessment of Pain
difference between experimental
and control groups on perceived
pain and respiration rates
Participants in the MT group
displayed significantly greater
behavioral distress (Mann
Whitney U, 9.69 vs. 4.58, p = .02)
and reported higher anxiety levels
during the treatment (MannWhitney
U, 9.79 vs.3.75, p = .002)
than the control group, however
had significantly less variance in
heart rate (MannWhitney U, 4.75
vs.8.58, p = .003)
A statistically significant difference
was found between the level of
engagement and behavioral distress
in the active and passive groups
compared with the nonengaged
group (Tukey's test, p = .000)
Results showed different trends in
findings based on age. Subjects
who were 15 years or older
experienced the greatest benefits
667
10
Audio-taped lullabies can help

reduce distress for children
receiving immunizations
A statistically significant decrease
in pain for all patients occurred at
30 minutes (ANOVA, F = 4.39,
p b .05) and was maintained at
60 minutes
The distraction group demonstrated
a statistically significant reduction
in pain compared with the other
groups at 30 minutes; this reduction
was maintained at 60 minutes
(repeated-measures ANOVA,
F = 47.07, p b .05)
Distraction techniques can be
effective in adjunct to analgesia for
children with musculoskeletal pain
668
Table 2 (continued)
Study no.
Reference
Study Focus
Sample
Method
Index; and physiological measures
(heart rate and blood oxygen level)
were measured
2. Audiovisual distraction: television

13
Data from Landolt Effect of cartoon movie
et al. (2002)
viewing as a practical and
low-cost technique to
reduce pain in burn patients
during dressing changes
14
Data from Salmon

et al. (2006)
Effect of procedural
narration and distraction on
children's memory of and
distress during a VCUG
(x-ray of the kidneys)

412 years)
Single-subject experimental design

Experimental condition: cartoon
movie plus a standardized
analgesic medication
Control condition: standardized
analgesic medication only
Observer ratings of behavioral
distress using the OSBD

2.57.5 years)
Experimental design
Assignment to 1 of 3 conditions:
1 - Complete procedural
information during the
VCUG, with cartoon video
(CI + D)
2 - Limited procedural
information, with a cartoon
video (PI + D)
3 - Limited procedural
information (standard care, PI)
Observer ratings of distress were
collected via the Child-Adult
Medical Procedure Interaction
Scale-Revised, and interviews
were conducted with participants
1 week after the intervention
Findings
from MT; children and adolescents
under 15 years of age experienced
less benefit
No statistically significant effect was
found during cartoon movie
distraction on observed behavioral
distress in patients
Cartoon movies may not be a
sufficiently effective in reducing
preschool children and children's
distress during burn dressing
changes
Compared with the PI condition
(standard care), participants in the
CI + D condition recalled
significantly more information
(t[52] = 2.07, p b .05), reported
the VCUG as less painful, and were
significantly less distressed
differences between the
PI + D and PI conditions were
found
Procedural narration together with
distraction can enhance preschool
children's and children's memory
and reduce distress during an
invasive procedure
Note: EDA = electronic dental anesthesia; NNS = nonnutritive sucking; MT = music therapy; VCUG = voiding cystourethrogram.

predominantly consist of listening to a story or music,
viewing television, or watching movies. Finally, some
studies compared the effectiveness of active versus
passive forms of distraction. Tables 1, 2, and 3 provide
summaries of the studies categorized under the various
forms of distraction.
Active Distraction
Active forms of distraction promote a child's involvement
in an activity during a procedure. These methods require
participants' active engagement and therefore tend to involve
several sensory components. Some of the most commonly
employed forms of active distraction in clinical settings
consist of interactive toys, VR, controlled breathing, guided
imagery, and relaxation.
Interactive Toys (Electronic and Video Games)

Interactive video and electronic games are multisensory
toys involving audiovisual, kinesthetic, and tactile senses,
requiring a player's active cognitive, motor, and visual skills.
To be played successfully, avid attention is necessary, and it
is common for children to become so engrossed in these
games that their surroundings become nonexistent (Dahlquist, Pendley, et al., 2002). For this reason, electronic games
are viewed as an active distraction technique with the
potential of blocking multiple senses for the reduction
of pain and anxiety (Dahlquist, Pendley, et al., 2002; Patel
et al., 2006).
Researchers in this area have evaluated the effect of
distraction on patients undergoing preoperative care (Patel
et al., 2006), cancer treatment (Dahlquist, Busby, et al.,
2002; Dahlquist, Pendley, et al., 2002), and venipuncture
(MacLaren & Cohen, 2005). Most researchers cite
interactive games as effective in reducing the anxiety and
stress of pediatric patients undergoing invasive procedures.
Dahlquist, Pendley, et al. (2002) evaluated the effects of a
Touch and Discover electronic toy as a diversion method,
with preschool children receiving repeated injections for
chemotherapy. The toy is interactive and involves auditory,
visual, motor, and tactile stimulation. Age-appropriate
images are depicted on a screen with child characters
instructing participants how to play; the game requires
specific photos to be touched to elicit correlated sounds.
This study reported a statistically significant decrease in
anxiety and distress with the use of the toy as reported by
the participants' nurses and parents, paired sample t test,
t(28) = 4.96, p b .01; t(28) = 2.52; p = .02. Notably,
results were maintained over the 8-week duration of the
chemotherapy treatment.
A similar study was conducted by Patel et al. (2006),
with 112 children between the ages of 4 and 12 years to
determine what types of distraction were most effective in
669
decreasing anxiety prior to surgery. The group that
received an interactive handheld video game in addition
to having their parents present prior to surgery experienced
a statistically significant 63% decrease in anxiety. In
contrast, anxiety decreased by 28% for the group provided
only with parental presence and 26% for the group that
had both parental presence and oral midazolam (chi-square
test, 2 = 9.26, df = 2, p = .01).
In summary, some studies report benefits associated with
the use of interactive toys and electronic games. Given the
range of electronic toys and games available on the market
today, additional research is necessary. For example, specific
types of games and toys may be more effective and
appropriate for pediatric patients. Indeed, child life specialists working in pediatric settings do not recommend games or
toys that feature violence or horror-like images. Despite
generally favorable reviews of this intervention, careful
choices must be made regarding the types of games offered
to pediatric patients.
Virtual Reality
VR technology provides a computer-based, three-dimensional interactive environment with auditory, visual, and
often tactile components. VR is novel, multisensory, and
believed to hold an advantage over other distraction
techniques by virtue of its cocoon-like equipment and its
engaging and immersive nature (Dahlquist et al., 2007). Set
in an enclosed headset, VR provides the opportunity for a
mental escape by strategically drawing individuals into an
alternative world. By controlling their perceptual environment, patients can redirect multiple senses from a hospital
environment to one involving positive and entertaining
activities (Gold, Kim, Kant, Joseph, & Rizzo, 2006;
Schneider & Workman, 2000; Wolitzky, Fivush, Zimand,
Hodges, & Rothbaum, 2005).
VR is supported as a feasible and useful tool of
distraction for children and adolescents undergoing cancer
treatment (Gershon, Zimand, Pickering, & Rothbaum,
2004; Sander et al., 2002; Schneider & Workman, 2000;
Wolitzky et al., 2005), burn treatment (Sharar et al., 2007),
and IV placement (Gold et al., 2006). A reduction in the
level of pain (Gershon et al., 2004; Sharar et al., 2007),
anxiety (Gershon et al., 2004), time focused on pain
(Sharar et al., 2007), and behavioral distress (Wolitzky
et al., 2005) is reported.
The nature of the VR software has been most effective
when tailored to a specific diagnosis or treatment. For
example, some researchers have evaluated the effectiveness
of VR as a distraction technique for burn victims by
presenting unique forms of software such as Hunter and
Petterson's SnowWorld a (Sharar et al., 2007). This program
is a three-dimensional virtual environment intended to create
an illusion of freezing ice. The environment comprises
Study no.
670
Table 3
Active and Passive Distraction

Study Focus
Data from Bellieni

et al. (2006)
Effect of active or passive

distraction during
venipuncture in children

712 years) undergoing
venipuncture
Gender of participants was
not specified
Sample
Data from
Berenson et al.
(1998)
Effect of video eyeglasses

for reducing anxiety
induced by the pelvic
examination among
children of different races

38 years) scheduled to
undergo a genital
examination
specified
Data from
Dahlquist et al.
(2007)
Effect of active versus

passive distraction using a
VR type head-mounted
display helmet for children
experiencing cold processor
pain
Method
Findings

trial design
Randomly divided into 3 groups:
1 - Control group, no distraction
2 - Mothers performed active
distraction
3 - TV group, cartoons were used
for passive distraction
Participant and parent self-report
measures collected to measure
distress (type of measures not
specified)
trial design
distraction groups during genital
examination:
1 - Passive play (being read to)
2 - Active play (singing, blowing
bubbles)
3 - Viewing a movie through
video eyeglasses
Levels of vocalized distress and
distress expressed by physical
behavior and requests for
emotional support were observed
and recorded
Participants reported their level of
satisfaction at the end of the
examination
trial design
conditions:
1 - Active distraction (play a
video game)
2 - Passive distraction (watch a
prerecorded footage of someone
else playing a video game)
3 - No-distraction control
condition
Pain threshold and pain tolerance
Procedures performed during TV

watching (passive distraction) were
indicated as significantly less
painful than control or procedures
performed during active distraction
(MannWhitney U, SD [24.5 vs.
21.36 vs. 8.65, p b .05)
TV watching can be more effective
than active distraction performed
by parents
Findings demonstrated lowest
levels of physical distress among
children who used video glasses
(univariate F test, F[2, 77] = 4.1,
p b .02) and highest levels of
physical distress among children
who were randomly assigned to
passive play (post hoc, p b .05)
Participants using video glasses
expressed significantly higher
levels of satisfaction than those
randomized to active play
(KruskalWallis, p = .001)
Viewing a movie through eye
glasses can be effective in reducing
distress in children undergoing
genital examinations
Participants in both active and
passive distraction groups showed
a statistically significant
improvement in pain tolerance/
threshold when compared with
baseline in Trial 2 (post hoc
analyses, M = 14.73, SD = 4.10
vs. M = 28.86, SD = 5.55, p b
.001; M = 19.70, SD = 3.95 vs.
M = 27.08, SD = 5.34, p = .02)
Participants in the control condition
showed no improvements in pain
Reference
Data from
MacLaren and
Cohen (2005)
Comparison of 2 distraction
modalities, interactive toy
and movie, against a
standard care control group
for venipuncture distress in
children
88 infants, preschool
children, and children (age
range = 17 years) receiving
venipuncture at a university
hospital
52 male and 36 females

trial design
Participants were grouped by age
(13 and 47) and randomly
assigned to 1 of 3 conditions:
1 - Standard care (control)
2 - Active toy distraction (toy)
3 - Passive distraction (movie)
Demographic data, observational
measures (Observation Scale of
Behavioral Distress), participant
and parent self-reports (scale not
specified), nurse self-report (VAS),
and observational coding were
collected
Data from Mason

et al. (1999)
Effect of using distraction

for reducing children's pain
and distress during
procedures

27 years)
Range of cancer diagnoses
3 male and 4 female
Experimental repeated-measures
design
3 conditions:
1 - Control
2 - Brief film
3 - Short story delivered during
repeated procedures in a
randomized sequence
Observers collected distress ratings
via the OSBD. Overall behavioral
distress was also obtained
Data from
Prabhakar et al.
(2007)
Effect of audio and

audiovisual distraction in
management of anxious
pediatric dental patients

48 years) with no previous
dental experience
specified
Experimental design
Assignment into 1 of 3 groups:
1 - Control
2 - Listened to audio presentation
through headphones during
treatment
tolerance or threshold
The active condition for pain
threshold was significantly more
effective than the passive condition
(t = 2.683, p b .01)
Participants in the passive group
(movie) were significantly more
distracted and less anxious than
children in the active condition
(ANOVA with follow-up t test,
t[51] = 2.74, p b .01)
Children in the active group were
more distracted than children in the
control condition (ANOVA with
follow up t test, t[52] = 6.84,
p b .01)
difference in distress between
active condition and standard care
condition
A passive strategy may be more
effective than an interactive
distraction during venipuncture
Pairwise comparisons using the
Wilcoxon matched pairs signed
ranks test found the mean ranks for
the observer ratings of overall
behavioral distress for the short
story intervention was significantly
lower than both the control group,
z(N = 7) = 2.23, p b .05, and
cartoon film intervention,
z(N = 7) = 2.05, p b .05.
Simple parentchild interactive
distraction tasks, such as engaging
in a short story, could be used by
parents to reduce child's distress
during procedures
Statistically significant difference was
observed between the control group
and audiovisual group (p b .05)
In the audiovisual group, a highly
significant (p b .01) pulse rate was
observed between the first and
671
measured
672
Table 3 (continued)
Study no.
Reference
Study Focus
Sample
Data from Sparks

(2001)
Effect of 2 forms of
distraction, touch and
bubble blowing, on
injection pain in preschool
children

46 years) needing DPT
immunizations
Data from
Stevenson et al.
(2005)
Effect of CCLS
intervention during routine
peripheral venous
angiocatheter insertion on
child procedure-related
distress in ED

Method
Findings
3 - Shown audiovisual
presentation
through television during
treatment
Observer ratings collected via the
Venham's Picture Test and
Venham's Rating of Clinical
Anxiety and physiological
responses (pulse rate and oxygen
saturation) measured to determine
participants anxiety
third visit, between the first and

fourth visit, between the second
and third visit, and between the
second and fourth visit.
Between the second and fourth
visit, the audiovisual distraction
group demonstrated a statistically
significant difference in anxiety
levels (p b .05)
Audiovisual distraction was
statistically more effective in
managing anxious pediatric dental
patients
Both forms of distraction, touch
and bubble blowing, had
statistically significant effects on
reducing injection pain perception
(ANOVA, F = 6.48, p = .013)
Group that received CCLS

intervention showed a statistically
significant difference over standard
care on stress and behavioral
measures in participants 47 years
old. Mean difference of 3.28 OSBD-r
units (95% confidence interval =
0.146.41, p b .05). Statistical
analysis included chi-square or Fisher
exact test for categorical variables and
independent 2-tailed Student's t test
for continuous variables
differences in child or parent
anxiety or customer satisfaction
between groups
Quasi-experimental design
3 treatments with their DPT
injection:
1 - Touch
2 - Bubble blowing
3 - Standard care
Prior to injection, a measure of fear
was obtained using the Child
Medical Fear Scale
Pain was measured via the Oucher
Scale
trial design
Random assignment to CCLS
intervention or standard care
Following assessment of child,
CCLS chose visual or auditory
distraction, breathing exercises,
singing, or verbal interaction.
Participants' anxiety collected via
the OSBD-r, the State-Trait
Anxiety Inventories, and customer
satisfaction surveys
Data from
Windich-Biermeir
(2007)
Effect of self-selected
distracters (bubbles, I Spy:
Super Challenger book,
music table, VR glasses,
handheld video games, or
bubbles) on pain, fear, and
distress in patients with
cancer undergoing port
access or venipuncture
with cancer
Intervention-comparison group
design
Patients randomly assigned to
comparison group (standard care)
or intervention group (distraction +
standard care)
The intervention group received a
full explanation of the procedure,
parental presence during the
procedure, the use of a topical
anesthetic over needle puncture
site, and a self-selected distraction
(books, music, handheld video
game, VR glasses or bubbles)
Participant self-reports rated pain
and fear, parents rated participants'
fear, and nurses rated participants'
fear and distress and conducted
interviews. Scales included CAS,
Glasses Fear Scale, Observation
Scale of Behavior Distress, and the
investigator-developed IV Poke
Questionnaire
The intervention group showed

significantly less fear and distress
as rated by the nurse and parents
during and after the procedure
(MannWhitney U, 9.42 3.93,
8.3 1.7, p = .03)
Self-selected distraction has the
potential to reduce fear and distress
during port access and venipuncture
Note: DPT = diphtheriatetanuspertussis; CCLS = certified child life specialist. GBAS = global assessment of behavioral reactions scale; VAT = visual analogue toy.
673
674
scenery depicting cold rain, icy hills, and snow. Multisensory
interaction using computer keyboard, joystick, mouse,
and/or head and eye movements is required by patients.
Research examining the effects of Hunter and Petterson's
SnowWorld a for patients undergoing burn treatment supports it as an effective means of distraction (Sharar et al.,
2007). Patients' self-reported subjective pain ratings based
on a 0100 graphic rating scale (GRS) comprised the main
outcome measure. This allowed the investigators to assess
patient ratings for intense pain, pain unpleasantness, and time
spent thinking about pain (Sharar et al., 2007). The study
found that all participants, regardless of age, had a significant
mean reduction (20%) in worst pain intensity from standard
care (SAS d, GRS, 54.2 3.1 vs. 43.5 3.5, p = .003), 26%
decrease in pain unpleasantness (SAS d, GRS, 41.0 3.6
vs. 30.3 3.0, p = .01), and 37% decrease in the time
spent thinking about pain (SAS d, GRS, 47.1 3.5 to 29.5
3.0, p = .001).
Although outside the temporal boundaries of this review,
Schmitt et al. (2010) recently conducted a randomized
controlled, within-subjects study with 54 patients (619
years old) examining the effects of Hunter and Petterson's
SnowWorld a . The findings demonstrate a significant
decrease in pain ratings (p b .05) and improved affect
(fun) during VR (p b .001). The analgesia and affect
improvements were maintained over multiple therapy
sessions, suggesting that VR is an effective nonpharmacologic adjunctive pain reduction technique for the pediatric
burn population.
In addition to tailoring images to suit the diagnosis or
treatment, VR can be administered wearing a helmet
(immersive) or not wearing a helmet (nonimmersive). In a
recent study, investigators examined the effects of using
nonimmersive VR during a needle-related procedure on
reported pain or distress of patients aged 518 years in a
pediatric oncology unit (Nilsson, Finnstrom, Kokinsky &
Enskar, 2009). Nilsson et al. (2009) assigned 21 participants
to an intervention group (nonimmersive VR) and another 21
participants to a control group. Both groups underwent either
venous punctures or subcutaneous venous port devices.
Before, during, and after the procedure, the patient rated his
or her pain intensity and distress by using the Color
Analogue Scale (CAS) and Facial Affective Scale (FAS).
The Face, Legs, Activity, Cry, and Consolability (FLACC)
scale was developed to measure observational pain in
children. Heart rate was recorded by a pulse oximeter 5
minutes before and during the procedure. Semistructured
interviews were conducted at the end and later analyzed
using qualitative content analysis. Participants found nonimmersive VR to be an enjoyable experience, and yet, their
reported pain intensity did not decrease (Nilsson et al., 2009).
In another study, Dahlquist et al. (2009) compared
nonimmersive and immersive forms of VR. Forty-one
participants, aged 614 years, were involved in two
distraction trials in which they played the same videogame
with or without the helmet. Their task was to place their hand

in cold water. After each trial, the pain threshold (elapsed
time until the participant reported pain) and pain tolerance
(total time they kept the hand submerged in the cold water)
were measured (Dahlquist et al., 2009). Another group
received no VR. Children and adolescents between the ages
of 10 and 14 years who wore a helmet demonstrated
statistically significant increases in pain tolerance (analysis
of variance [ANOVA], M = 70.08, SD = 71.22)then younger
participants (t = 2.193, p b .05) aged 69 years old. Results
from this study showed that both distraction conditions
resulted in improved pain tolerance when compared with
those using no videogames (Dahlquist et al., 2009). Finally,
Gershon et al. (2004) conducted a study with children and
adolescents with cancer from 7 to 19 years of age.
Participants who required port access were randomly
assigned to a VR distraction intervention, a non-VR
distraction, or treatment as usual without distraction.
Throughout the procedures, pain and distress evaluations
were collected, pulse rates were monitored, and behavioral
distress was observed. ANOVA tests were used with post
hoc analysis to examine the treatments in the three
conditions. They found a decrease in the staff ratings of
participants' pain and distress as indicated by significantly
lower pulse rates during VR (p b .05) compared with the
other two conditions. No significant differences were found
for the non-VR condition versus the no-distraction condition
on pulse rate.
In summary, VR is a complex and costly method that
holds promise as an effective intervention. Several authors
have called for larger sample sizes and more heterogeneous
participants to determine how VR can be used most
effectively (Dahlquist et al., 2009; Gershon et al., 2004;
Gold et al., 2006; Lange, Williams, & Fulton, 2006; Sharar
et al., 2007; Wolitzky et al., 2005). It appears that wearing
a helmet versus not wearing a helmet may be more
effective for patients between the ages of 10 and 14 years,
as noted by Dahlquist et al. (2009), whereas Nilsson et al.
(2009) added that comparisons between nonimmersive VR
(no helmet) and games showed no differences in reported
pain intensity. However, Dahlquist et al. (2009) used a
proxy stimulus for pain. Clinicians may need to determine
whether immersive or nonimmersive forms of VR are
appropriate for particular patients, taking into consideration
the age and temperament of the patient. Finally, some
authors call for more research to test the efficacy and
feasibility of VR across a range of noninvasive and invasive
or potentially more distressing procedures (Gershon et al.,
2004; Lange et al., 2006).
Controlled Breathing
Controlled breathing can be characterized as a cognitive
behavioral distraction technique in which patients deliberately pace their breathing. It is considered an active form of
diversion that induces relaxation (Lal, McClelland, Phillips,

Taub, & Beattie 2001; Peretz & Gluck, 1999; Sparks, 2001).
Controlled breathing has been studied using bubble blowing
(Sparks, 2001), breathing exercises (French, Painter, &
Coury, 1994; Peretz & Gluck, 1999), and party blowers
(Manne et al., 1990).
Most research involving controlled breathing have
included children undergoing minor procedures such as
immunizations (e.g., routine shots; French et al., 1994;
Sparks, 2001), anesthesia injections for dental surgery
(Peretz & Gluck, 1999), and venipunctures (Lal et al.,
2001; Manne et al., 1990). Some of these studies have
reported a reduction in pain and expressed pain behaviors
for children adhering to controlled breathing exercises
(French et al., 1994; Peretz & Gluck, 1999). For example,
Manne et al. (1990) tested the use of party blowers
combined with parental coaching and positive sticker
reinforcements to help reduce pain and stress during
venipuncture for invasive cancer treatment. The intervention group was compared with an attention control group
in which parents were encouraged to use their own ideas to
divert their child's attention during treatment. Although
there was a significant reduction in preschool children's
and children's distress, parental rating of their child's pain,
and parental anxiety (Pearson's r, p b .001), children's
perception of pain was not meaningfully affected by the
behavioral intervention (Manne et al., 1990). These authors
suggest that because measures of preschool children and
children's self-reported pain did not produce statistically
significant results, party blowers may be less effective than
more interactive activities for patients from 3 to 9 years
old undergoing invasive cancer treatments. Further research is required to determine the use of controlled
breathing over time (i.e. multiple invasive procedures;
Manne et al., 1990) and how it compares with other forms
of active distraction.
Guided Imagery and Relaxation

Guided imagery is another cognitivebehavioral technique intended to help pediatric patients reach a state of
relaxation that can influence the body's pain perception
(Huth, Van Kuiken, & Broome, 2006). It is simple,
noninvasive, self-regulative, cost-effective, and appropriate
for preschool children, children, and adolescents who have
creative imaginations (Ball, Shapiro, Monheim, & Weydert,
2003; Huth, Broome, & Good, 2004; Weydert et al., 2006).
Distraction through guided imagery and relaxation has
been implemented in a variety of ways. Pediatric patients
are most often guided in muscle relaxation and then
encouraged to let their minds wander, imagine, and focus
on a scene/ environment that is pleasurable, peaceful, or
relaxing. Other forms of guided imagery are facilitated
through audio prompts such as the envisioning of a story
(Ball et al., 2003; Broome, Lillis, McGahee, & Bates, 1994;
Lambert, 1999; Weydert et al., 2006).
675
Guided imagery and relaxation have been evaluated as a
means of reducing pain and anxiety in preschool children,
children, and adolescents (Broome et al., 1994; Huth et al.,
2004; Lambert, 1999; Pederson, 1995; Weydert et al., 2006),
which can in turn affect parental anxiety and distress
(Broome et al., 1994) and decrease missed activities due to
pain (Weydert et al., 2006). In general, research supports
guided imagery and relaxation as effective distraction
techniques for decreasing pain and anxiety in pediatric
patients (Ball et al., 2003; Huth et al., 2004; Lambert, 1996;
Pederson, 1995).
In a recent study, investigators examined the effectiveness
of a guided imagery program using a compact disc (CD)
program by Mehling, Highstein, and Delamarter (1990),
titled Magic Island: Relaxation for Kids. This CD was
designed by child life specialists to reduce postoperative
pain, increase relaxation, and stimulate imagery in children
and young adolescents (Huth, Daraiseh, Henson, & McLeod,
2009; Smart, 1997). A sample of 17 children and adolescents
between the ages of 7 and 12 years were assessed before and
after listening to the CD, and pain and relaxation scores were
generated to assess the CD's effectiveness in reducing
postoperative pain, increasing relaxation, and stimulating
imagery (Huth et al., 2009). Results of this study showed that
listening to the CD stimulated the imagination of 14 (82%) of
the 17 children (Huth et al., 2009). Participants also reported
significantly lower pain scores from pre- to postintervention,
paired t test, t(15) = 3.49, p = .0033; however, no meaningful
increase in relaxation was reported, thereby suggesting that
relaxation may not be a necessary component for pain
reduction but rather that stimulating imaginations might be
beneficial (Huth et al., 2009).
In other studies, guided imagery resulted in statistically
significant decreases in the number of missed activities due
to pain and the number of days in pain, which can lead to
improved social functioning (Huth et al., 2004; Weydert
et al., 2006). Weydert et al. (2006) conducted a study with
22 children and adolescents aged 518 years. The
participants were separated into two groups; the first
group received guided imagery and progressive muscle
relaxation, whereas the second group received only
progressive muscle relaxation. Group results were compared
using the chi-square or Student's t test. Findings demonstrated that participants in the guided imagery group
coupled with breathing exercises experienced a greater
statistically significant decrease in the number of days with
pain during the initial month (67% vs.21%, p = .05) and the
following month (82% vs.45%, p b .01). Accordingly, this
group also demonstrated a greater statistically significant
decrease of days with missed activities during the initial
month (85% vs. 15%, p = .02) and the following month
(95% vs. 77%, p = .05).
Huth et al. (2004) conducted a study with 73 children
aged 712 years to investigate the effectiveness of imagery
and routine analgesics in reducing anxiety and tonsillectomy
and/or adenoidectomy pain after surgery in the hospital and
676
at home. This study found that there was a statistically
significant decrease in pain postoperatively between the two
groups during their recovery in hospital, multivariate
analysis of covariance [MANCOVA] at T2, F(3.66) = 3.02,
p = .04. Although these studies appear to have similar
findings, there were differing effects over time, with Weydert
et al. (2006) finding that the impact of guided imagery was
sustained over the long term, whereas Huth et al. (2004)
found the effects short lived. For example, guided imagery
proved effective in reducing pain when the participants were
in a highly anxious state, but results were not always
sustained after they returned home (Huth et al., 2004).
Taken together, active forms of distraction can produce
favorable outcomes for preschool children, children, and
adolescents experiencing various levels of pain. In some
cases, the ability to participate in active forms of distraction
may require situations in which mild to moderate pain levels
are expected. It is also reasonable to assume that based on
developmental level, some preschool children may have
difficulty engaging in activities that demand considerable
cognitive capacities (e.g., guided imagery, VR).
Passive Distraction
Passive forms of distraction require that the child remain
calm and quiet during a procedure. In this case, distraction is
achieved through patients' observation of an activity or
stimulus rather than their overt participation. Auditory and
audiovisual techniques are the most common forms of
passive distraction used with pediatric patients.
Auditory Distraction: Music

Music is a widely used form of auditory distraction
because it is noninvasive and inexpensive and requires no
active engagement (Aitken, Wilson, Coury, & Moursi, 2002;
Tanabe, Ferket, Thomas, Paice, & Marcantonio, 2002).
Edwards (1999) wrote a review of the literature addressing
music therapy and found that singing familiar songs and
listening to music were generally effective techniques for
distracting pediatric patients from pain and distress during
procedures. In addition, music is hypothesized to induce
relaxation and compete with pain stimuli to reduce anxiety
and perceived pain (Baghdadi, 2000; Gousie, 2001; Joyce,
Keck, & Gerkensmeyer, 2001; Malone, 1996; WhiteheadPleaux, Baryza, & Sheridan, 2007).
Types of auditory distracters include live music (Gousie,
2001; Malone, 1996; Whitehead-Pleaux, Baryza, & Sheridan, 2006) and recorded music and sounds (Baghdadi, 2000;
Bo & Callaghan, 2000; MacLaren & Cohen, 2005; Megel,
Houser, & Gleaves, 1998; Smart, 1997; Tanabe et al., 2002).
The type of music examined in the literature varies; some use
upbeat sounds (Aitken et al., 2002; Arts et al., 1994),
whereas others use calm sounds (Aitken et al., 2002).

Auditory distraction techniques have been administered
to infants, preschool children, children, and adolescents
undergoing dental treatment (Aitken et al., 2002; Baghdadi,
2000), venipuncture (Bo & Callaghan, 2000; Malone, 1996),
IV cannulation (Arts et al., 1994), allergy testing (Jeffs,
2007), circumcision (Joyce et al., 2001), musculoskeletal
pain (Tanabe et al., 2002), injections (Gousie, 2001; Malone,
1996), and burn treatment (Whitehead-Pleaux et al., 2006;
Whitehead-Pleaux et al., 2007). Many of these researchers
report that age-appropriate music is effective at distracting
patients by increasing relaxation (Baghdadi, 2000), relaxing
patients by decreasing procedural pain (Gousie, 2001; Joyce
et al., 2001; Tanabe et al., 2002; Whitehead-Pleaux et al.,
2007), anxiety (Whitehead-Pleaux et al., 2007), and distress
(Gousie, 2001; Malone, 1996; Megel et al., 1998; Whitehead-Pleaux et al., 2007).
In one mixed-method study, live music had a positive
effect on burn patients aged 716 years (Whitehead-Pleaux
et al., 2007). Participants believed that music induced
relaxation and fostered greater coping while decreasing the
time required for the procedure. In another study, Gousie
(2001) found that music was correlated with improved
interactions among pediatric patients, parents, and health
care professionals in addition to facilitating greater pain
management and quicker recovery times. Music can be
offered in conjunction with other pain management techniques, such as medications or anesthesia (Joyce et al.,
2001). For example, Tanabe et al. (2002) found that the
combination of music and administration of anesthetics
proved most statistically significant in reducing pain
(KruskalWallis, z = 1.97, p = .048).
In contrast, several studies refute the efficacy of music for
decreasing anxiety or pain in preschool children, children,
and adolescents (Aitken et al., 2002; Arts et al., 1994; Megel
et al., 1998; Whitehead-Pleaux et al., 2006). Disparate
findings may be due to the length and type of treatment, the
patient's age and exposure to the painful stimuli prior to
introducing music (Bo & Callaghan, 2000; Gousie, 2001;
Malone, 1996; Whitehead-Pleaux et al., 2007), and the levels
of acute pain experienced during a procedure (WhiteheadPleaux et al., 2007). Researchers call for more clearly
designed, well-controlled studies on the use of music as a
cognitivebehavioral strategy for pain management (Joyce
et al., 2001; Whitehead-Pleaux et al., 2006).
Audiovisual Distraction: Television

Televisions are particularly commonplace in pediatric
hospitals. They are cost-effective, easily accessible (Cohen,
Blount, & Panopoulos, 1997), and entertaining (Cassidy
et al., 2002). Studies have included evaluations of children
watching television during venipunctures (Bellieni et al.,
2006; MacLaren & Cohen, 2005), burn treatments
(Kelley, Jarvie, Middlebrook, McNeer, & Drabman, 1984;
Landolt, Marti, Widmer, & Meuli, 2002), cancer treatments
(Mason, Johnson, & Woolley, 1999), genital examinations

(Berenson, Wiemann, & Rickert, 1998), voiding cystourethrograms (Salmon, McGuigan, & Pereira, 2006), and
immunizations (Cassidy et al., 2002; Cohen et al., 1997).
Some studies have found television to be successful in
decreasing perceived pain (Bellieni et al., 2006; Berenson
et al., 1998; Cohen et al., 1997) and alleviating distress
(MacLaren & Cohen, 2005) during a variety of procedures.
In a randomized control study comparing parental support
versus television watching, television was more effective in
distracting children from pain (Bellieni et al., 2006).
Berenson et al. (1998) compared passive movie distraction
through video eyeglasses with passive distraction (being read
to) and a form of active distraction (singing and blowing
bubbles). They report that viewing a movie through
eyeglasses was effective for preschool children and children
undergoing standard genital examinations. Watching a
movie was significantly more effective at reducing anxiety
and distress than singing and blowing bubbles or being read
to, as children viewing television with video eyeglasses had
the lowest levels of distress, univariate F test, F(2, 77) = 4.1,
p b .02).
In contrast, several studies show that television and
movies are insufficient at reducing pain or distress during
procedures when compared with other methods (Cassidy et
al., 2002; Landolt et al., 2002; Mason et al., 1999; Salmon et
al., 2006). For example, Mason et al. (1999) found both short
stories and interactive toys as more effective than watching
television during painful procedures, z(N = 7) = 2.05, p b
.05. In a randomized control study comparing the effectiveness of watching television versus watching a blank screen,
Cassidy et al. (2002) found that regardless of whether the TV
was on, a reduction in pain was experienced by children who
shifted their focus to the screen. They concluded that
distraction in and of itself can have an analgesic effect.
Because the use of television or movies appears to offer
limited degrees of effectiveness, some researchers recommend more interactive audiovisual strategies (Cassidy et al.,
2002). For example, Cohen et al. (1997) suggest that the
combination of different techniques, such as additional
coaching by a nurse in conjunction with television, could
foster better outcomes.
Comparing Active and Passive Forms

of Distraction
Comparisons between active and passive forms of
distraction have led to mixed and inconclusive findings
(Bellieni et al., 2006; Berenson et al., 1998; MacLaren &
Cohen, 2005; Mason et al., 1999; Sparks, 2001). Active
strategies are often hypothesized as superior to passive
distraction because they demand multisensory engagement
that intercepts multisensory pain stimuli (Dahlquist et al.,
2007; Dahlquist, Pendley, et al., 2002; Mason et al., 1999;
Peretz & Gluck, 1999; Windich-Biermeir, 2007). The notion,
677
however, that more invasive or painful procedures require
engagement from a variety of senses is empirically
supported. In one study comparing two distraction techniques (auditory versus audiovisual distraction for dental
patients), researchers found that multisensory modalities
served to distract multisensory pain stimuli and thus were
significantly effective in reducing anxiety levels during
painful procedures (p b .05; Prabhakar, Marwah, & Raju,
2007). In another study with 2- to 4-year-old oncology
patients, interactive stories (active) were compared with
watching a cartoon movie (passive), and researchers found
that the active form distraction produced less distress during
treatment (Mason et al., 1999).
MacLaren and Cohen (2005), however, reported different
results. Their study compared two distraction modalities
against a standard care control group: passive movie versus
interactive toy on eighty-eight 1- to 7-year-old participants
undergoing venipuncture. The toy intervention involved
interactive cognitive, visual, and auditory components
compared with a cartoon movie involving passive auditory
and visual stimulation with no child engagement. Here, the
passive technique was found to be significantly more
effective than the interactive toy and standard care,
ANOVA follow-up t test, t(51) = 2.74, p b .01. MacLaren
and Cohen (2005) suggest that active forms of distraction
may be too demanding for some children experiencing pain,
whereas a passive technique may be more effective.
In a study by the authors of this review, active and passive
forms of distraction were compared by measuring pain and
anxiety in 5- to 18-year-olds undergoing angiocatheter
insertion in an ED (Goldman, Koller, Wan, Bever, & Stuart,
in review, 2011). Following randomization, 39 patients
received active distraction, whereas another 40 were
assigned to a passive group. The Observational Scale of
Behavioral Distress-Revised (OSBD-r) was used to assess
participants' anxiety behaviors during angiocatheter insertions. Eight categories, such as flailing, crying, and verbal
fear, were recorded as absent or present, and a score was
calculated according to the incidence and severity weights
from the distress behaviors. In addition to anxiety, selfreported pain was assessed by using the Faces Pain ScaleRevised (FPS-R). The FPS-R is a self-report measure
designed to gauge pain intensity. The scale contains six
faces aligned in increasing pain intensity at equal intervals.
The FPS-R is widely used to assess acute pain in patients 4
years and older.
Child life specialists administered the distraction and were
only told prior to the procedure which form was to be used.
Participants were allowed to choose an activity from a list of
possibilities associated with their group. Active forms
included blowing bubbles or playing with a toy, whereas
passive distraction entailed listening to a story from a book,
watching a video, or listening to music. Analyses showed no
statistical difference in the pain and anxiety scores between
the two groups. There was a statistically significant
difference, however, in the number of attempts for IV
678
insertion, with more children in the passive group requiring
two or more attempts (t test, 1.19 0.64 vs. 1.82 1.34, p =
.02). Given the degree of pain and anxiety associated
with needles (Koller, 2008), coupled with the resource
demands within pediatric EDs (Stevenson, Bivins, &
O'Brien, 2005), the use of active distraction and the role
of the child life specialist in pediatric EDs should be
considered a best practice (ED Management, 2004; Goldman
et al., in review, 2011).
In contrast, some passive forms of distraction are touted
as more effective than active strategies because the
requirement for engagement in active distraction can be
challenging for some children experiencing pain and distress
(Bellieni et al., 2006; Berenson et al., 1998; MacLaren &
Cohen, 2005). As in the case of Sparks (2001), active
(bubble blowing) and passive (touch) forms of distraction
were compared on 105 participants aged 46 years old
undergoing immunization. Both interventions were significantly effective in reducing perceived pain (ANOVA, F =
6.48, p = .013), although touch was administered continuously throughout the procedure and resulted in the lowest
pain scores, suggesting that some participants may have
found bubble blowing too challenging. Therefore, a primary
advantage associated with passive techniques is that it
demands little of the patient except for their attention to the
stimuli. In contrast, active methods rely on participants'
willingness and ability to engage in the activity.
Discussion
The intent of this review was to critically assess the
literature on distraction techniques used in pediatrics to
inform clinical practice and identify future research directives. Based on this review, emerging issues related to
distraction techniques appear inextricably linked to the
existing gaps in research. The following discussion will
address methodological issues and key gaps that have
implications for clinical decision making. Emphasis is
placed on the need to acknowledge child preferences as a
way of revealing best practices and endorsing child
participation rights in health care decisions.
Few Direct Comparisons Between Types and Forms

of Distraction
The limited research comparing methods of distraction
makes it difficult to delineate best practices. Each intervention can differ on multiple dimensions, and both active and
passive forms can produce varying levels of engagement and
success. Moreover, the types of distraction are not
adequately isolated or tested within some studies and are
administered in conjunction with other approaches, which
can include parent or nurse coaching (Cohen et al., 1997;
Dahlquist, Busby, et al., 2002; Manne et al., 1990; Mason

et al., 1999) or positive reinforcement strategies (Manne
et al., 1990).
Another area that lacks attention concerns the effectiveness of novel approaches to those that have been around for
many years. For instance, Berenson et al. (1998) evaluated
the use of video eyeglasses, whereas Dahlquist, Pendley, et
al. (2002) examined the Touch and Discovery interactive toy.
In both cases, these items were novel, and yet, there was no
analysis provided regarding their novelty and nor were they
compared with established methods. Given that the very
principles associated with distraction relate to its ability to
hold a child's attention, the effects of distraction can alter
and/or diminish once the novelty wears off and the child
becomes habituated. Further research comparing distraction
methods and accounting for prior exposure in addition to
personal preferences is needed (Lange et al., 2006; Schneider
& Workman, 2000).
Issues Concerning Methodologies

Because there exists a strong correlation between
perceived pain and anxiety (Kuttner, 2010), evaluating
children's and adolescents' responses to procedures is most
accurately assessed using a multidimensional approach (i.e.,
self-report, observational measures, and/or physiological
indicators) (Whitehead-Pleaux et al., 2006). However, valid
pain assessment tools are not always used or readily available
(Manne et al., 1990), and there exists a lack of objective
distraction measures (Cassidy et al., 2002; Cohen et al.,
1997). Despite the predominant use of quantitative measures
and scales, some authors cite the need for larger sample sizes
to increase the validity and generalizability of the findings
(Dahlquist, Busby, et al., 2002; Gold et al., 2006; Mason et
al., 1999; Salmon et al., 2006; Whitehead-Pleaux et al., 2006;
Wolitzky et al., 2005). Finally, there exist few qualitative
studies, which adequately address pediatric patients' personal experiences with distraction techniques. As others have
noted, the examination of health care experiences merit the
use of qualitative or inductive approaches, which can provide
a more nuanced understanding of complex phenomenon
(Charmaz, 1990; Coyne, Hayes, & Gallagher, 2009;
Woodgate & Kirstjanson, 1996).
Lack of Attention to Child-Specific Variables

The child's age, developmental level, temperament, and
type of treatment can affect coping during procedures (Arts
et al., 1994; Carlson et al., 2000; Gousie, 2001; Koller, 2008;
Schneider & Workman, 2000). For example, children who
have strong social skills may be more willing to engage in
active forms of distraction, whereas more inhibited children
may prefer to observe an activity. In pediatric settings, child
life specialists often address these issues in determining the
most suitable distraction strategy and methods of delivery for
individual patients (Cramer-Berness & Friedman, 2005).

Current literature focuses on participants less than 12 years
of age, and less is known about effective forms of distraction
for adolescents (Cassidy et al., 2002). Finally, future research
should address the short- and long-term impacts of distraction
within particular diagnoses or treatment groups (Dahlquist
et al., 2009; Gershon et al., 2004; Gold et al., 2006; Manne
et al., 1990; Sharar et al., 2007).
Implications for Clinical Decision Making

Overall, the studies reviewed here support distraction as
a coping strategy for pediatric patients. In terms of active
distraction, the evidence supports the use of controlled
breathing, VR, guided imagery/relaxation, and interactive
toys and electronic games. However, Manne et al. (1990)
indicated that the pain experienced by preschool children
and children can affect the success of these interventions, in
particular, controlled breathing. Passive forms such as music
and television are generally viewed as effective, although
some believe these forms may work best in combination
with other methods (Bo & Callaghan, 2000; Tanabe et al.,
2002). Similar conclusions are offered elsewhere in reviews
of this literature (see Chambers, Taddio, Uman, &
McMurtry, 2009).
In spite of these conclusions, making decisions regarding
interventions for pediatric patients remains a difficult task.
Given the many forms of distraction that include various toys
and electronic equipment, the choices are endless. As
technology evolves and new gadgets and toys are introduced,
health care professionals are continually challenged by novel
ways to support patients through procedures.
Despite these challenges, the key to delineating best
practices can be found in identifying individual patient
preferences and temperament. In particular, the sense of
control pediatric patients can experience from choosing a
distraction activity may compensate for the lack of control
involved in treatment (Kaminski, Pellino, & Wish, 2002;
Sparks, 2001). Although Goldman et al. (in review, 2011)
found no differences in pain and anxiety scores between the
active and passive distraction groups, all participants had the
opportunity to choose an activity from a list of possibilities
assigned to their group. In addition, when participants did not
follow instructions assigned to their distraction group
(passive or active), the child life specialist would permit
the alternative method. For example, if a participant assigned
to the passive group began to participate in the distraction
technique (e.g., reaching for the bubble blower or asking to
play with the toy), the child life specialist would allow them
to engage. These alterations were analyzed using intentionto-treat analysis. Hence, the effectiveness of particular
distraction techniques may be influenced by the patient's
ability to self-select a method he or she believes will be
helpful. Rather than relying exclusively on the research
examining the effectiveness of distraction methods, health
care providers should consider patient choice an integral part
of clinical decision making.
679
To date, there are no studies that address patient choices
regarding distraction, the role of temperament, and associated levels of pain and anxiety. For instance, individuals with
temperaments characterized by high anxiety may have lower
pain thresholds or may be unable to engage in active
distraction. As others have acknowledged, the number of
possible distraction interventions combined with individual
preferences and differences may influence the outcomes
(French et al., 1994; Manne et al., 1990). As noted by
Chambers et al. (2009), more research should address which
strategies work best for patients of varying ages and whether
certain child characteristics, such as temperament, anxiety
level, and cognitive ability, require nuanced approaches.
Because health care professionals are not always
available, research should examine how patients and parents
initiate or engage in distraction techniques. In one study,
children aged 810 years were taught a distraction technique.
At a 2-year follow-up, these children showed greater
tolerance to a painful procedure than did controls who did
not receive distraction training (Tsao, Fanurik, & Zeltzer,
2003). The active participation of patients in identifying
suitable coping strategies appears to hold promise of better
health outcomes. As such, fostering the participation of
children in health care decisions should be considered an
integral part of clinical decision making. Evidence-based
practice in this area dictates that health care professionals
identify opportunities for child and parent engagement that
can decrease stress and improve patient outcomes (Bond,
Lee, Mandleco, & Donnelly, 2003). To ensure best practices,
child preferences and participation in health care decisions
must be acknowledged so that patient's treatment of choice is
promoted rather than provider's choice of treatment.
Acknowledgments
We gratefully acknowledge the contributions of Ora
Kalfa, Rebecca Mador, Anam Haji, and Michelle Pegler.
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Journal of Pediatric Nursing (2012) 27, 652681

Distraction Techniques for Children Undergoing Procedures:

Ryerson University, Toronto, Ontario, Canada

PAIN IS A complex, multidimensional and subjective

Corresponding author: Donna Koller, PhD.

Brewer, Syblik, Tietjens, & Vacik, 2006; Howard, 2003;

Distraction Techniques for Children Undergoing Procedures

1. Interactive toys (electronic and VGs)

6 preschool children and

During the distraction

Effect of an electronic toy as a

29 preschool children (age

Effect of an HMD helmet in VG

41 children and adolescents

D. Koller, R.D. Goldman

Data from Patel

Effect of a handheld interactive

112 preschool children and

Randomized, prospective study

The group that received an

59 children and adolescents

Pilot study: randomized

During VR, participants had

(continued on next page)

Distraction Techniques for Children Undergoing Procedures

Data from Gold

20 children (age range = 812

Effects of using nonimmersive

recorded throughout the

D. Koller, R.D. Goldman

The self-reported pain

30 children and adolescents

11 children and adolescents

20 children and adolescents

VAS pain scores tended to be

(continued on next page)

Distraction Techniques for Children Undergoing Procedures

Data from Lal

Effect of an active distraction

149 preschool children

environment during the

p b .01, and had significantly

Participants who were under

D. Koller, R.D. Goldman

The use of party blowers

23 preschool children and

Effect of an active distraction

indicating the effectiveness of

(continued on next page)

Distraction Techniques for Children Undergoing Procedures

and during the venipuncture

4. Guided imagery and relaxation

Gender of participants not

assigned to the intervention

expressed their wish to have

Effect of guided imagery and

Effect of distraction and

Pilot study: randomized

D. Koller, R.D. Goldman

pain behavior and facial display

Data from Huth

Effect of imagery, in addition to

73 children (age range =