INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE, 4(4), 364-377 Copyright © 1997, Lawrence Erlbaum Associates, Inc Cognitive Coping Skills Training in Children With Sickle Cell Disease Pain Karen M. Gil, Jennifer J. Wilson, Jennifer L. Edens, Elizabeth Workman, Jawana Ready, Jan Sedway, Rupa Redding-Lallinger, and Charles W. Daeschner ‘This study was designed to examine whether brief training in cognitive coping skills would enhance pain coping strategies and alter pain perception in children and adolescents with sickle cell disease (SCD). Forty-nine participants with SCD were randomly assigned to cither a cognitive coping skills condition or a standard care control condition. At pre-and posttesting, coping strategies and pain sensitivity using laboratory pain stimulation were measured. Results indicated that. in comparison to the randomly assigned control condition, brief training in cognitive coping skills resulted in decreased negative thinking and lower pain ratings during low intensity laboratory pain stimulation Key words: sickle cell disease, laboratory-induced pain, coping skills training; disease-re- lated pain; pediatric pain Karen M. Gil, Jennifer J. Wilson, Jennifer L. Edens, Elizabeth Workman, Jawana Ready and Jan Sedway, Department of Psychology, University of North Carolina, Chapel Hill, NC, USA; Rupa Redding-Lallinger, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Charles W. Daeschner, East Carolina University School of Medicine, Greenville, NC, USA This work was supported by Grant ROL HL46953-06, by Project VLB.2 in the Duke Univer- sity-University of North Carolina Sickle Cell Center Grant in P60HL2839-13, and by the University of North Carolina at Chapel Hill GCRC Grant RROO046. We thank the staff of Duke University-University of North Carolina Sickle Cell Center including ‘Susan Jones, Thomas Kinney. Dell Strayhorn, William Schultz, and Cynthia Brown, We also thank Laura Porter, Jodi Prochaska, Lauren Raezer, and Yolanda Van Hor for help with data collection and entry; David Johndrow for help with data analyses; and Crawford Clark and Malyin Janal for assistance with the sensory decision theory procedures and analyses. Correspondence concerning this article should be addressed to Karen M. Gil, Department of Psychology, Davie Hall, CB 3270, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3270.COPING SKILLS TRAINING 365, Sickle cell disease (SCD) is a major health problem, affecting approximately | in 500 African Americans. SCD refers to a group of genetic disorders characterized by chronic anemia and both acute and chronic organ damage (Charache, Lubin, & Reid, 1994). The most frequent problem encountered by children with SCD is vasocclusive pain. Most children experience several unpredictable and severe painful episodes each year (Shapiro & Ballas, 1994). Despite promising advances in medical treatments, there is currently no cure for SCD pain. Response to pain varies considerably to the point at which some children rarely miss school or require health care services. Many are able to manage painful episodes at home by taking oral analgesics, resting, and increasing fluid intake. At the other extreme, children may miss considerable amounts of school, become depressed, become inactive, and seek frequent and intensive health care service. Some studies, for example, have found that about 50% of children meet criteria for a psychiatric diagnosis such as depression or anxiety. Our previous studies found that coping strategies explained significant portions of the variance in pain report and psychosocial and functional adjustment in children with SCD, even after controlling for frequency of episodes and demographics (Gil et al., 1993; Gil, Williams, Thompson & Kinney, 1991). Children who reported using many cognitive and behavioral attempts to deal with pain had fewer emer- gency room visits and were more active during painful episodes, whereas children who were more passive in their approach had more emergency room visits and were less active. Children who reported high levels of negative thinking had greater psychopathology. Recently, we have incorporated laboratory pain stimulation and sensory decision theory (SDT) analyses (Clark, 1987, 1994) into our disease-related pain research (Gil et al., 1997; Gil et al., 1995). There are a number of advantages to using these methods to study clinical pain. Clinicians presume that pain report in children with disease-related pain reflects both an underlying noxious stimulus (ischemia secon- dary to intravascular sickling) and an interpretation of that sensation. Stimulus intensity may differ across children and across episodes for the same child. Some children respond immediately and intensely to sensory input, whereas others endure greater stimulation before they report pain. These factors can present problems to health care providers attempting to evaluate the various components of the child’s pain report. The use of calibrated pain stimuli provides a reliable means to standardize the noxious stimulus under controlled laboratory conditions, and to more precisely examine individual variation in pain report and response (Edens & Gil, 1995). Several prior studies have demonstrated the utility of laboratory pain paradigms in healthy children. A series of three studies using the cold pressor task demon- strated that this paradigm is feasible to use and nonstressful to children and parents (Fanurik, Zeltzer, Roberts, & Blount, 1993; LeBaron, Zeltzer, & Fanutik, 1989; Zeltzer, Panurik, & LeBaron, 1989). In addition, the laboratory model offered a366 9 GILET AL. systematic and controlled approach for evaluating pain management interventions in healthy children (Fanurik et al., 1993). In one study using a finger pressure task to study children with disease-related pain, Walco, Dampier, Hartstein, Djordjevic, and Miller (1990) demonstrated that this method was a reliable and valid approach to examining pain perception in children with clinical pain secondary to SCD or juvenile rheumatoid arthritis. Moreover, they found that children with SCD had lower pain thresholds than healthy children suggesting that physical and/or psy- chological factors related to chronic disease may influence report of pain threshold. SDT analyses provide advantages over traditional methods to assess pain perception. More traditional methods, such as the threshold measure, combine sensory and psychological influences on pain report into a single index (Clark, 1987, 1994). SDT provides the ability to quantify separately the sensory (discrimi- nation) and attitudinal or psychological (report criterion) components of pain report (Chapman & Loeser, 1989; Clark, 1994). The discrimination index is the ability to differentiate between stimuli of different intensities. High (sharper) sensory dis- crimination is indicated when the participant consistently reports high pain for high intensity stimulation and low pain for low intensities; poor discrimination results when the participant provides similar ratings regardless of intensity level. The report criterion or response bias index independently measures the participant's general tendency to report pain during noxious stimulation due to motivational or attitudinal factors. A high criterion indicates that the participant is stoic and gives few pain ratings, Whereas a low criterion indicates that the participant readily reports pain. Using laboratory pain methods and SDT analyses, we recently found that children who reported the use of active cognitive and behavioral coping strategies reported less pain (higher report criterion) during laboratory-induced stimulation (Gil et al,, 1997). These findings verify that frequent pain reports may be due in part to the way in which children interpret sensory experiences, not just the intensity of the noxious stimulation. Collectively, these studies suggest that laboratory pain paradigms may provide unique advantages in examining clinical pain report and response in children. An important implication of these prior studies is that psychological interven- tions that target coping strategies may lead to more effective overall pain manage- ment in children with SCD. Findings from research with other childhood pain problems suggests training in cognitive-behavioral coping skills leads to improve- ments in pain report, behavioral distress, and overall adjustment (e.g., Jay, Elliott, Woody, & Siegel, 1991; Sanders, Shepherd, Cleghorn, & Woolford, 1994; Walco, Varni, & Ilowite, 1992), Moreover, a few uncontrolled studies with small numbers of children with SCD have found that relaxation-based interventions lead to improvements in pain perception and health care use (Cozzi, Tryon, & Sedlacek, 1987; Zeltzer, Dash, & Holland, 1979), Also, in a recent controlled study of adults with SCD, we found that skills training resulted in improvements in coping and pain report (Gil et al., 1996).