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Stress Management Techniques in Childhood and Adolescence: Relaxation Training,

Meditation, Hypnosis, and Biofeedback: Appropriate Clinical Applications
Mark Scott Smith and William M. Womack
CLIN PEDIATR 1987 26: 581
DOI: 10.1177/000992288702601105
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in Childhood
and Adolescence

Management Techniques

Training, Meditation, Hypnosis, and Biofeedback:

Appropriate Clinical Applications
Mark Scott

Many childhood

and adolescent stress-related symptoms have

Smith, MD,* William M. Womack, MD†

psychophysiological compodysfunction.

nent that involves muscular tension and/or autonomic nervous system

Examples of
this include recurrent headache, chest pain, abdominal pain, syncope, and dizziness. After a

careful medical and

appropriate for the

psychosocial evaluation, the clinician may identify many patients who are
application of stress reduction techniques such as progressive muscular
relaxation, meditation, biofeedback, and relaxation/mental imagery (self-hypnosis). This review describes these techniques and their application with selected children and adolescents.


AND ADOLESCENTS often manifest symptoms that appear to have a strong psychophysiological component. It has become popular to
refer to predisposing conditions that precipitate such




Symptoms such as recurrent headache, chest pain,

abdominal pain, syncope, or dizziness must be evaluated in a comprehensive manner to rule out significant organic disorders as well as psychosocial problems such as physical and sexual abuse, substance
abuse, and fear of pregnancy. Particular attention
should be paid to the child or adolescents relationship with family, school, peers, and community. Dysfunction in any of these areas may be related to the

From the Departments of * Pediatrics and †Child Psychiatry and

Behavioral Medicine and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington.
Correspondence to: Mark Scott Smith, MD, Chief, Adolescent
Services, Childrens Orthopedic Hospital, 4800 Sand Point Way,
NE, P.O. Box C5371, Seattle, WA 98105.
Received for publication December 1986, revised March 1987,
and accepted April 1987.

presence of psychophysiological symptoms. Anxiety

disorders may present with a multitude of symptoms




and autonomic


system hyper-reactivity. Depression is commonly associated with somatization.4

The importance of a careful history and physical
examination with particular attention to the above
considerations cannot be overemphasized. Prior to
embarking on a behavioral approach to a presumed
psychophysiological symptom (e.g., tension headache), organic disorders must be adequately ruled

(e.g., slowly growing craniopharyngioma).

Some diagnoses such as a major depressive disorder or sexual abuse require referral to a mental
health or social service professional. Often, however,
the clinician may determine that stress-related symptoms are not associated with major psychosocial disorder and may appropriately be managed in the
primary care setting. Examples of the latter might
include muscle contraction headaches in an overachieving child, recurrent abdominal pain in a child
of a family undergoing divorce or frequent chest
pain in an adolescent with anxiety related to school


problems. In these situations, brief supportive counseling by the primary care clinician coupled with instruction in stress reduction techniques may provide
appropriate cost-effective treatment. This paper is
intended to review the use of stress reduction techniques in children and adolescents.


It is often



postulate a plausible physio-

logical mechanism associated with the presence of

any given symptom. For example, abdominal pain
may be related to dysfunction of intestinal motility or
aerophagia; chest pain may be related to hyperventilation syndrome with intercostal muscle spasm; and
frequent headaches may be related to prolonged
muscular contraction and vasomotor instability.
Children and adolescents and their parents are often
receptive to such explanations and may find them
useful in linking the presence of a symptom with an
underlying stressor. Additionally, such psychophysiological explanations provide a basis for the introduction of self-control behavioral techniques aimed
at symptom reduction.
It appears that the experience of deep relaxation is
common to most stress-reduction techniques and
perhaps an altered state of consciousness is an additional component. An altered state of consciousness
implies that the individual is experiencing a conscious state somewhat different than their usual one,
which is primarily focused on the external environment. The practice of stress reduction techniques involves becoming more absorbed in internal states by
focusing attention or using mental imagery. Progressive muscular relaxation, meditation, hypnosis, and
biofeedback have been shown to be effective in reducing psychophysiological symptoms in children
and adolescents.5-8
Since it has been difficult to demonstrate the superiority of one technique over another and individual
children and adolescents may have a preference for a
particular method, it is useful for the clinician to
have knowledge of several behavioral techniques for
stress reduction. As with any effective treatment,
rapport with the patient, suggestion, expectation of
credibility, and compliance are imin
successful interventions. Moderate
to severe depression may prevent successful patient



Stress Reduction Techniques



Progressive muscular relaxation teaches one to be

of varying degrees of muscle tension throughout the body.9 Through a series of exercises alternately tensing and relaxing various muscle groups, a
deep state of relaxation is produced. Particular emphasis is placed on perceiving the transition from


muscular tension to relaxation. The process is repeated with successive muscle groups throughout the
body until deep muscular relaxation is achieved. Abbreviated versions of Jacobsons original technique
have been developed that can be completed in approximately 15 minutes.lO,1l
The progressive muscular relaxation technique
does not require mental imagery or special equipment and the rationale for its use is understood by
most patients. The following case illustrates the use
of the progressive muscular relaxation technique.
A 15-year-old girl undergoing chemotherapy for

lymphoma began





each time intravenous therapy was instituted. She

described many kinesthetic sensations during these
episodes which included coldness of the extremities,
abdominal discomfort, &dquo;goosebumps,&dquo; and tachycardia. Although she was unable to use mental imagery
techniques successfully, she was very receptive to the
progressive muscular relaxation technique. With sequential tensing and relaxing of various muscle
groups and attention to the consequent sensations
over a 15-minute period, she was able to attain a
state of deep relaxation and decreased anxiety. She
was able to tolerate subsequent intravenous procedures without undue anxiety while listening to a tape
recording of the technique.

Meditation has been part of Eastern and Western

spiritual practice for centuries. Only recently has
meditation been applied to the management of medical disorders. 2,1 Although it is often used in spiritual development, the practice of meditation requires no particular belief system. The type that is
most applicable to the medical setting is concentrative meditation. This involves narrowly focusing the
attention of the mind onto a sound or symbol.

Transcendental meditation has been shown to be

associated with decreased oxygen consumption, carbon dioxide production, respiratory rate, and minute ventilation.&dquo; Benson demystified the technique
and instructed subjects in the use of a simple meditative technique using the word &dquo;one.&dquo;15 Benson
termed this technique the relaxation response. Instructions for use of the relaxation response are simple : 1) Sit quietly; 2) Close your eyes; 3) Deeply relax
all your muscles; 4) Become aware of your breathing;
5) Each time you exhale say the word &dquo;one&dquo; (or another word of your choosing) silently to yourself; 6)
If distracting thoughts enter your mind, simply
brush them aside and return to repeating the word
&dquo;relax;&dquo; 7) Do not evaluate your performance; 8)
When 20 minutes has passed, sit quietly for a few
moments, then gently and slowly open your eyes.
Meditation is a relatively passive technique and requires acceptance on the part of the subject. Some
adolescents, particularly those who have had experience with martial arts techniques, find the concept of
meditation intriguing.
A 17-year-old male with mild hypertension ranging from 140 to 150 over 90 during a 6 month period was evaluated medically and found to have essential hypertension. He had experience with karate
training and was receptive to the idea of using a meditation technique. He was instructed in the relaxation
response as described by Benson and encouraged in
his belief in &dquo;mind control&dquo; techniques. He practiced
the technique for 15 minutes twice daily, and over a
period of several months his blood pressure normalized. At a 6 month follow-up he was normotensive
and reported continued practice of the meditation
technique, which he enjoyed.

Clinical hypnosis usually involves relaxation and
the use of mental imagery. For this reason, and because of the stigma attached to the word, hypnosis
has been termed relaxation-mental imagery by some
authors.&dquo; Gardner has aptly defined hypnosis as &dquo;a
state of heightened concentration in which the patient who is willing and motivated may experience
alterations in sensations and perceptions and may be
more responsive to suggestions from the
which are consistent with the patients own
wishes.&dquo;17 In hypnosis there is a general decrease in
critical cognitive function resulting in what Hilgard

has defined


&dquo;subsidence of the



The subject who is receptive to hypnosis focuses
attention on an alternate state of awareness that
allows the acceptance of suggestions promoting perception or behavior which is ultimately compatible
with the subjects desires. During hypnosis, the child
or adolescent may achieve relief from symptoms and
additionally receive post-hypnotic suggestions allowing continued improvement or relief from symptoms
to carry over into the normal waking state. Although
not all children and adolescents are good hypnotic
subjects, most receive some benefit from the state of
deep relaxation that can be achieved. Hypnotic ability (suggestibility) peaks in the pre-adolescent years
and remains at somewhat lower levels throughout

The clinical use of hypnosis requires some training
and experience. Confidence, enthusiasm, and rapport generated by the therapist are important in
achieving clinical states of hypnosis. The clinical application of hypnosis is truly an art and there are
genuine masters of this technique. The interested
clinician, however, can achieve adequate competency
in hypnosis by participating in a workshop presented
by a reputable organization such as The American
Society of Clinical Hypnosis or the Society for Clinical and Experimental Hypnosis.
A 9-year-old boy experienced weekly common
migraine headaches for 3 years. A complete medical
evaluation was normal and the family history was
positive for migraine. He was motivated and receptive to instruction in self-hypnosis techniques. Following an eye-roll induction technique he visualized
himself walking through a pile of leaves which was
being blown away by the wind as he counted from
ten down to zero. He then imagined various scenarios (e.g., good &dquo;Transformers&dquo; subduing the evil
ones) that enhanced his sense of mastery and control
over headache mechanisms. After 4 weeks of practice for 15 minutes twice daily, the frequency of his
headaches decreased markedly. After 2 months of
practice he experienced only infrequent mild headaches, and at a 6 month follow-up visit he was headache free.

Biofeedback provides electronic signal detection

of physiological variables such as electromyographic


potentials, skin temperature, Galvanic skin response,

and electroencephalographic potentials.20,21 These
signals are amplified and displayed to the individual,
usually as auditory or visual information. Through
the monitoring of this previously unavailable information, and the application of what has been termed
&dquo;passive volition,&dquo; the subject learns to alter the specific physiological activity.
Skin temperature biofeedback is commonly used
to train subjects in fingertip warming. Since blood
flow to the skin of the hand is predominantly a function of sympathetic nervous system tone, vasodilation
and warming involves decreased sympathetic activity
in the hand.22 Vigorous and determined efforts to
influence the skin temperature are usually unsuccessful. It is when one is able to achieve a relaxed
passive state of awareness that the desired change

specificity of biofeedback training is debatable.2~24 Certainly biofeedback may be used to augment relaxation training and the electronic instruThe

mentation is often attractive to children and adolescents who may be less receptive to simple relaxation

imagery techniques. In addition, the feeling of

mastery and control frequently is reinforced with
successful biofeedback training.
A 16-year-old girl began experiencing frequent
syncopal episodes followed by throbbing headaches.
A complete medical evaluation including CT scan,
EEG, and 24 hour Holter monitoring yielded no abnormal findings. Psychiatric consultation found no
evidence for conversion disorder. The patient was
felt to be experiencing basilar artery migraine with
syncope and multiple trials of anticonvulsants and
Beta-blockers were unsuccessful in preventing at-


tacks. With

behavioral intervention she had diffi-

culty forming images and was not receptive to simple

progressive muscular relaxation exercises. She was
intrigued by the temperature biofeedback apparatus,
however, and proved to be an excellent subject who
could produce rapid and consistent fingertip warming. She received 6 temperature biofeedback sessions
and practiced home hand-warming techniques using
a liquid crystal temperature band on her fingertip.
After several sessions of biofeedback training coupled with home practice, she noted a marked decrease in syncopal episodes. After 6 weeks of training
she experienced no further episodes and remained
symptom free at a 1 year follow-up.



With appropriate patient selection, the primary

clinician may provide effective therapy for children and adolescents with symptoms which have a
psychophysiological component. Patients with significant psychological, social, or organic disorders must
have adequate management of the primary problem
prior to institution of stress reduction techniques.
The successful application of any stress reduction
technique requires some clinical training and experience. Progressive muscular relaxation and meditation techniques are accepted by many children and
adolescents and can be learned relatively easily by
the clinician. Effective hypnosis is accomplished only
after more extensive training and experience such as
that provided by The American Society of Clinical
Hypnosis or The Society for Clinical and Experimental Hypnosis. Biofeedback requires relatively expensive equipment and training in its use. There is no
solid evidence that any one technique is superior

another, although

some patients may prefer a

The successful use of any stress reduction technique requires rapport with the patient, patient receptivity, expectation of relief from symptoms, focusing, relaxation, and motivation to practice. Stress
reduction techniques provide adjunctive therapy to
indicated medical and psychological interventions;
they are not an appropriate substitute for them. For
example, providing only a behavioral intervention
for a child with chronic headaches who has an abusive family or who is suffering from a major depressive disorder is inadequate therapy. Following a careful medical and psychosocial evaluation, the clinician
may select children and adolescents who are good
candidates for the application of stress reduction
techniques. These patients may then receive brief
supportive counseling, instruction in an acceptable
technique, and several short follow-up visits to trouble-shoot practice problems and monitor progress.



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