Acute Procedural Pain in Children - Essay Example

Evaluate the contribution psychological factors may have to the experience of acute procedural pain in children Psychological factors play an important role in the instances where children experience acute procedural pain. There are both psychological aspects, to the occurrence of acute procedural pain as well as for relief from it. Recognizing and analyzing this intricate and complex relationship between acute procedural pain in children and psychology, is a step in the direction of resolving the problem. Acute procedural pain refers to the pain accompanying a surgical or other medical; procedure. Such kind of pain has an obvious end as the patient healing comes to a completion. However pain especially in children which goes undetected and is not comprehended or controlled from the beginning can have severe physiological, physical as well as psychological reparations and may further complicate the medical problem. Such an undetected pain may in the long run transform into chronic pain. Acute pain and even acute procedural pain has a particular cause that can be discerned and is a temporal pain. Though it’s generally considered as a protective mechanism the severity of feeling the pain varies largely. Extreme acute pain can cause a series of physiological changes that may prove fatal like diaphoresis, intensified breathing and increase in pulse rate and blood pressure. Acute procedural pain in children is unique especially because of a child’s (especially, small children and neonates) inability to communicate their pain to the caregivers in ways that can be discerned easily. More ever there are no scales to measure pain even in adults. Self depiction or reporting, a tactics, which cannot always be utilized in case of children, is perhaps the only accurate way to comprehend the amount of pain experienced. Pediatric pain management has been recognized as inadequate (Beyer, 1983, 1990; Mather & Mackie, 1983). Children have exceedingly distinct cognitive and emotional development from that of adults as they are still in the developmental stage. Moreover children in different age group are in different developmental age and so their reaction to pain may vary. Psychological factors like a since of security or lack of it, arising from the presence or absence of a specific type of care giver, also influences the pain experienced by children. The only way to elevate pain in children recovering from procedural intervention is to device ingenious ways to assessing and detecting it followed by effective pain management procedures. The efficiency of the pain management procedure thus depends both on the quality of assessment as well as the knowledge about the roots of the problem and how to relief or at least ease it to some extent. The AHCPR guideline emphasizes that medical and health professionals should focus on the child’s experience (psychological as well as physical) rather than on the procedural and technical aspects of care giving. AHCPR has set out specific guidelines based on various studies that children are actually able to depict the location and intensity of their pain when they are motivated to do so. (Atkinson, 1996; Carter, 1994; Craft & Denehy, 1990). At times their ability to express their pain may be reduced due to actual physical inability to do so due to pain or, because of their developmental stage, which sets various mental, psychological and physical limitation, due to anticipation or fear of pain if pain is detected, etc. (Atkinson, 1996; McCrory, 1991; Schmidt et al., 1994; Wilson). At various times children are unable to express their pain to medical personnel’s properly and even respond positively to pain management programs, in the absence of the immediate caregivers, like parents, due to various psychological factors. (Brain & Maclay, 1968; Frankl et al., 1962; Kay, 1966; Mason, 1978; Schulman et al., 1967; Thyer, 1992). So nurses and medical care givers should encourage children to depict and express their pain and listen to it and encourage care givers to carry out their role as pain relievers. Any attempt to play down feelings of pain in children may actually result in aggravating feelings of mistrust for the caregivers and aggravate anxiety in children. Erickson’s theory of psychological development studies the effects of social interaction on the development of ego identity of a child. Our social experience formed through social interaction determines the development or identity of self. The identiy develops out of the ability or in ability to overcome a particular conflict specific to a particular developmental stage of the children. For example in the first stage, from birth to first year a child has to overcome the conflict of trust VS mistrust in order successfully pass on to the second stage of development. In the case of children suffering from acute procedural pain, it is essential for the caregivers to help the child develop a sense of trust so as not to inhibit the development of ego identity at this stage. Neglecting or mismanagement of procedural pain in children can have various long-term effects. The effect of skin-to skin contact as an analgesic was tested in a study involving 30 full term infants. The studies found that when the diapered newborns were held against the mothers chest, their was more calming effect than when they were swaddled in a crib. (Reference: Gray L and others: Pediatrics 105(1): E14, Jan. 2000 in Wong on Web Paper) John Bowlby’s theory of attachment on proximity maintenance views attachment as a powerful emotion connected with perception and actual exchange of care and comfort. He proceeds to explain that a child value’s a secure base from where they like to operate. For example the children who express their pain in the presence of specific care givers like parents better. When in distress or pain they like to resort or come back to a safe haven and experience separation distress in the absence of a safe haven. Thus the absence of a comforting care giver can actually cause distress or pain in children experiencing acute procedural pain. Piaget's cognitive developmental theory states that cognitive development or growth of intelligence occurs in stages in children. Hence children in different developmental groups may have different capability to represent the outside world as well as well as carry out activities or respond to this representation depending on their schemata at that particular age. Hence according to him intelligence is developed due to acquisition of knowledge based on the child’s interaction with the world as well as by self-motivated actions. Thus a toddler is capable of responding to acute procedural pain or represents it specific to his/her stage of cognitive development. Health personnel’s and caregivers should therefore listen carefully to the child’s description and be sensitive to any small behavioral indication of pain, and not disbelieve or down play it or base assessment of pain merely on behavioral observations. Many children do not actually verbalize their pain or express it. They consider withdrawal or non-acknowledgement of pain to be a kind of protection from other painful actions that have a potential of being carried out in case pain is detected. Moreover adolescents may actually perceive acknowledgement to be a sign of weakness or defense less situation on which they lack control. If children are in such a crucial developmental period the effects of acute and unmanaged procedural pain on the vulnerable mind’s of children and its impact on cognitive development needs to be studied. From various studies by AHCPR (not directly investigated) it has been found that anticipatory distress or anxiety that can actually aggravate post procedural pain can be triggered by disturbances in the hospital environment. (Romsing & Walther-Lars The finding that children do not express pain due to unpleasant memories associated with it and due to anticipated pain due to action taken after pain is detected could be correlated with the conditioning theory. Memories or visit to a hospital where a painful procedure was carried out may actually trigger pain as the child associate’s hospital with the experience of pain and becomes conditioned to it. For children in hospitals and under acute procedural pain any perception of activity may cause distress and trigger pain due to anticipation of painful procedures. A Childs pain tolerance and threshold may be determined by various biological, cultural and psychological factors (APHR, 1992). It has also been found that there is strong nexus between distress, anticipatory fear or pain and actual pain and the distinctions cannot be made lucidly. (Fradet et al., 1990). It has been found in various research studies that extreme unalleviated pain can lead to a sort of overpowering stress response in both premature as well as full term infants which resulting in various severe complication (changes in the cognitive and neural system and sometimes even death. (Pasero, 2004). More ever neonates or premature babies are sometimes incapable to demonstrate behavioral indications of pain (like crying etc) but can be more vulnerable to pain then full term babies. Often the experience of pain felt by babies, both full term and premature or paralyzed babies is mis- represented or under represented as there are few ways to detect and measure pain Morton (1998). Scales for measurement of pain should be suitable for the cognitive development of a child at a particular age. The Department of Pediatrics and the Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri, carried out a study on 152 infants and repeated it on as many as 135 infants (pre-term and full-term) to find if the amount of response of infants varies with changes in invasiveness of the medical procedure, differences as a result of gestational age and concept ional age (related to the extra uterine age) and how these pains are subjectively rated by medical or clinical personnel’s. From the results of the findings it is suggested that to marginalize the long-term effect of procedural pain (development, intensity and response) it is crucial to adopt an effective pain management mechanism at the early stages of life. Drawing from the findings of the result it is suggested that while pain for pain full procedures should be sought to be removed by “pharmacologic” relievers, “non-pharmacological” techniques should be also used even when there is no detection of pain. The test finding show that infants are capable of discriminating in the intensity of invasive procedures even in the first week and this is independent of the gestational age. Tests were conducted to determine the effect on the latter development due to acute procedural pain. It was found that newborns can actually differentiate between more and less intense procedural pain, while the detection of difference between moderate and more invasive pain may not be detected. In the early stages premature baby’s response to procedural pain is same as that of full term babies but with increase in time of extra uterine procedure the responses are more easily detected and more intense. In fact premature babies may be more sensitive to pain. However the studies revel that medical personnel’s are not able to detect response of pain in pre-mature babies to different intensities of pain due to lack of robust responses. As a result of these misconceptions pain management in infants is inadequate. The findings results also suggest that the effects of pain in infants may have cause permanent damage. Reinterpretation Freud's psychoanalytical theory is of particular importance in this context. Though Freud analyzed the psychosexual effects on latter development, it can be deduced in this case that development of phobia’s and unsubstantiated fears latter on in life may be due to the effect of these early inappropriate or inadequate management of pain. Pain is generally perceived to be a strong indicator of any damage or injury to the body (internal or external). Pain is conceived as a protective apparatus because it helps to sent signal that attention has to be paid, the source and cause of the pain detected and appropriate actions taken to elevate pain. International Association for the Study of Pain puts forth a definition of pain as “an unpleasant, subjective, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (1979).”(Quoted in Pain: Its Nature and Experience Persis Mary Hamilton). Pain is also a complicated interrelation of physical, cognitive, sensory and emotional mechanism which is also different for different individuals. Since pain is such a real yet subjective experience it cannot be quantitatively or objectively measured. Pain should be accepted as it is expressed to be felt by a particular individual. The American pain society makes it clear that the patients need not prove the existence of pain rather the caregiver or the health giver should accept it and work towards its elevation. Hence the assessment or the recognition of pain, especially in the case of children is of utmost importance for devising pain management tactics, comfort or cure. Again since pain and the intensity of pain is also a result of emotional and psychological factors operating with other factors, it is important to understand the psychological aspect of pain. Contrary to the earlier belief pain is not merely symptomatic, a result of a response (pain) to a stimuli(injury or damage) and various empirical studies have gone on to substantiate the fact the pain has emotional, physical as well as cognitive dimensions. The experience of pain interferes with normal functioning, and hinders daily activities like sleeping, eating, movement, self-image, emotional well fare, independence, self-actualization, performance, sexual drive etc. However there is very little comprehension and efforts for treatment of pain. The concentration is more on the treatment of the disease. A study of the influence of the psychological factors on pain may actually help in enhancing the patient’s receptiveness to medical techniques for pain relive through their active implementation. It has been found certain people are more sensitive to pain than other, and that the capacity to tolerate pain as well as the pain threshold (the intensity of pain when it can be detected by the subject) varies from individual to individual. Certain pains (like those from advanced cancer) cannot be relieved easily and are highly resistance to even medical interventions. Hence there is a need to understand and find out how other disciplines even psychology can lend a hand to reduce the suffering. (Persis Mary Hamilton, 18th Nov 2005). Moreover pain can be of different kinds and difficult to find a logical explanation for it at times. For example in phantom limb pain a pain is felt in the limp that has been severed as a result of distortions of perception in the cognitive area or brain. There are some pains, which are felt in areas far removed from the site of the injury or damage. The psychological effects of positive reinforcement by a sympathetic caregiver, touch therapy, distraction, soothing music has profound effect in elevating the feelings of pain. In certain cases a child in acute procedural pain may find a secure haven of comfort in certain types of caregivers and the feelings of pain may be significant in the absence of that particular care giver. Certain specific stimuli may become associated with the experience of pain, although there is no actual connection, and may trigger pain. For example a child may become conditioned to associate the antiseptic smell of a hospital with his/her pain .In presence of this smell, which has become associated with pain, when the brain sends out panic signals of false pains which is actually felt by the child. When a child resents a particular situation feelings of pain actually develop although they may be perceived as illusions or pretensions by an adult. For example when a child wants to skip school by saying he/she has a stomachache this is often perceived as pretensions by an adult. A scheme to delude the adult and escape going to school. The child may in fact actually feel a churning stomach pain. Such misperception by an adult leads him/her to respond in a way that may actually aggravate the symptom. A proper understanding of the psychological factors affecting a child in acute procedural pain enables the health cares and caregivers to provide positive reinforcement, which helps elevate the symptom. A parent or a nurse in care of a child who complains of acute pain when ever the date for chemotherapy nears would be able to understand the psychological factors at play. They would be then able to provide positive reinforcement, by talking positively, providing comforting touch and thus easing pain. Hence pain full memories can play a large role in eliciting acute pain and may cause a reduction in an individual’s capacity to tolerate pain. Such memories become deep rooted especially when an individual is a child when the pain or the association occurred and can be felt long after the painful procedure has been stopped. For elucidating the nexus between psychological mechanisms of thought and emotions and the experience of pain Melzack and Wall propounded a theory the gate-control theory (1982). The theory explains that according to the gate like process is initiated when the impulse of pain is transmitted to the spinal nerves. The T cells in the spine, which trigger pain, affect the conduction of the pain impulse. But when the activity of the T cells, which open the gate to triggering pain, is suppressed the pain impulses have far less chance of being transmitted to the brain. The controlling mechanism of transmission of pain impulse by the T-cells is in fact situated in the nerve fibers located in the thalamus and the cerebral cortex. These sites in turn are those areas of the brain concerned with thoughts, feelings, emotions and beliefs. By reinforcing positive thoughts, feelings of well being, imagery and even distraction perception of pain can be altered and pain can be elevated to a large extent. The relation of distraction to pain was analyzed on a Meta-analysis of 19 studies among 535 children between 3-15 years. Various distraction methods like music, party games and entertainment devises like kaleidoscope was used to distract the children from the pain experienced as a result of variety of medical procedures like IV, BMA, LP, IM and dental procedures. Through the self-reporting of pain and observation of distress behavior it was found that distraction did in fact result in substantial reduction of pain. (Kleiber C & Harper DC: Nurse Res 48(1):44-49, 1999.) It has been found that the perception of pain differs in adults and children. Children in different developmental age have age specific perception and response to pain. Premature babies and newborn babies both are born with an ability to feel pain and this doesn’t require any learning. However premature babies have greater sensitivity to pain. Pain can be detected by observing their behaviors, like crying, facial countenance etc. Infants as young as 1 month can Infants can associate caregivers with comfort Toddlers on the other hand are able to explain the site of the pain to some extent, react to it with anger , melancholy, crying, as well as perceive pain as a sort of punishment for which others are responsible. They learn to associate memories of hospitals or painful procedures, injections, knife etc with pain. School going children on the other hand may try to veil their pain in an effort to seem brave, and revert back to their earlier developmental periods. Teenagers on the other hand may hid their pain and withdraw as they perceive any admittance of pain to be a weakness. Regression to the preceding stages of development may be observed even in adolescence encountering prolonged pain. From various studies by AHCPR (not directly investigated) it has been found that anticipatory distress or anxiety that can actually aggravate post procedural pain can be triggered by disturbances in the. Since pain is of such crucial importance and has significant implications, various organizations have developed standards of pain assessment and management. A biosocipsychological approach top pain management taking into consideration the biological, psychological and social factors has to be devised. Standards of pain management by Joint Commission on Accreditation of Healthcare Organizations standards, accredited facilities have polices like recognizing that a patient has a right to effective pain assessment, its nature and intensity, follow ups and record of assessment: that it is assessed by experts in the field; educating the patient and the family to recognize and manage pin appropriately. The American Academy of Pediatrics lays down various guidelines and policies for pain management in children.   Research studies of the nervous system have come up with the results that demonstrate that psychological factors are of fundamental significance in management of and elevation of pain. Psychological assessment is done with the consideration for differences in individuals, their genetic history and social environment related to pain. Hence an interdisciplinary approach to the exclusion of merely individual therapy is adopted. It has been substantiated that cultural and social factors can determine how children respond to pain or acute procedural pain. Certain cultures and societies discourage the expression of pain or promote expression of pain in a very distinct manner. Importance should be paid to the influence of thought, belief and fears in how a child responds to and copes with pain. An interdisciplinary technique for management of pain should be adopted to avoid and simplistic solutions to a complicated mechanism, namely experience of man and coping with it. Although parents are better able to interpret ate pain symptoms in children then other care givers it has been found that parents version of how much pain is felt by a child may be different than that of a self-report of a child. Studies have found out that witnessing the procedures amplifies the pain. These and the above considerations should be taken into account while managing pain and assessing it. Bibliography And References AMERICAN ACADEMY OF PEDIATRICS(online)available at http://www.pediatric.aappublications.org Hamilton Mary Persis, Pain: Its Nature and Experience, 2006,Nursing continuing education, (online) available at http://www.nursingCEU.com Task Force on Pain in Infants, Children, and Adolescents, The Assessment and Management of Acute Pain in Infants, Children, and Adolescents Committee on Psychosocial Aspects of Child and Family Health, PEDIATRICS Vol. 108 No. 3 September 2001, pp. 793-797 Task Force on Pain in Infants, Children, and Adolescents, CURRICULUM ON PAIN FOR STUDENTS IN PSYCHOLOGY Prepared by the IASP ad hoc Subcommittee for Psychology Curriculum(online) available at http://www. International association for the study of pain_psychology curriculum.com The recognition and assessment of acute pain in children Technical Report Guideline objectives and methods of guideline development, Clinical practice guideline, (online) available at http://www.cpg_econtent.com Wong on Web Paper Evidence-Based Pediatric Pain (online) available at http://www.mosbysdrugconsultant.com Read More