Puin, 62 (1995) 3-9 3

Elsevier Science B.V.

PAIN 2740

Research Papers
A comparative study of cognitive behavior therapy versus genera1
anesthesia for painful medical procedures in children

*, Charles H. Elliott ‘, Irma Fitzgibbons a,b,Patricia Woody a and Stuart Siegel a*b
Susan Jay aYb,
LIChildren S Hospita1 of Los Angeles, Los Angeles, CA 90064 (USA),
b Universify of Southern Califomia School of Medicine, Los Angeles, CA 90064 (USA) and
’ Department of Psychology, 7he Fielding Znstitute, Santa Barbara, CA (USA)

(Received 11 January 1994, revision received 30 September 1994, accepted 20 October 1994)

Summary A treatment outcome study was conducted to compare the efficacy of cognitive behavior therapy
(CBT) versus genera1 anesthesia in alleviating the distress of 18 pediatrie cancer patients (ages: 3-12 years)
undergoing bone marrow aspirations (BMAs). CBT and short-acting mask anesthesia were delivered within a
repeated-measures counterbalance design. Results indicated that children exhibited more behavioral distress in the
CBT condition for the 1st minute lying down on the treatment table. However, parents rated significantly more
behavioral adjustment symptoms 24 h following the BMA when their children had received anesthesia. NO
differences were found in childrens’ and parents’ preferente for CBT versus anesthesia.

Key words: Pain; Pediatrics; Painful medical procedures

Introduction efficacy in two different oncology settings with over 100

Bone marrow aspirations (BMAs) are highly aver-
sive diagnostic medical procedures administered to
children with cancer. BMAs involve the insertion of a
large needle into the child’s hip bone (posterior ileac
crest), followed by the suctioning-out of marrow with a
syringe, in order to examine the marrow for the pres-
ence or absente of cancer cells. Often, only a local
injection of lidocaine is administered which anes-
thetizes the skin surface and the bone but does not
lessen the pain associated with the suctioning of the
marrow.
Previous research has documented extreme and vir-
tually ubiquitous distress in children undergoing BMAs
(Katz et al. 1980; Jay et al. 1983). A cognitive-behav-
ioral intervention package was designed to reduce chil-
dren’s procedure-related distress and is a standardized
intervention protocol that has demonstrated consistent
?? Corresponding author: Susan Jay, Pb.D., 11500 W. Olympic Av-
enue, Suite 380, Los Angeles, CA 90064, USA. Requests for
reprints should be sent to Joan Bryant, Reprint Dept., The
Fielding Institute, 2112 Santa Barbara Street, Santa Barbara, CA
93105, USA.
children as young as 3 years of age (Jay et al. 1985,
1987, 1991).
As relatively effective and widely accepted as this
cognitive-behavioral intervention package seems to be,
it has not eliminated children’s distress associated with
BMAs. Mean reductions of observed behavioral dis-
tress range from 18 to 50% after intervention (Jay et al.
1985, 1987, 1991). These are both statistically and
clinically significant findings, yet the remaining distress
exhibited by some children has been discouragingly
high.
This high residual distress led US to conclude that
perhaps medical approaches should be investigated, at
least for some children for whom psychological inter-
vention does not provide adequate amelioration of
distress. A variety of premedication agents have been
used for procedure-related distress including DPT (de-
merol, phenergan, and thorazine); oral fluritrazepam
combined with intravenous fentanyl; and oral valium,
but with limited success and/or unacceptable side
effects (see Zeltzer et al. 1990; Maunuksa et al. 1986;
Jay et al. 1987, 1991, respectively). Some experts be-
lieve that short-acting genera1 anesthesia is a highly
preferable alternative to premedication for outpatient
procedures or surgery (Forbes 1983) In fact, short-

SSDZ 0304-3959(94)00216-9
 acting genera1 anesthesia is administered routinely in
Europe to children undergoing BMAs (Campbell et al.
1979; Hain et al. 1985; Leeuw et al. 1987) but is used
on a much more limited basis in the United States in
only a few of the larger pediatrie oncology centers (sec
Fisher et al. 1985; Ferrari et al. 1990).
In particular, the safety and low incidence of nega-
tive side effects of halothane have been well-docu-
mented. The possible complication of post-halothane
jaundice and liver toxicity has been studied in two
retrospective studies (Wark 1983; Warner et al. 1984)
which assessed the risks of jaundice associated with
halothane to be between 1 in 82,000 and 1 in 200,000,
respectively. Furthermore, in a prospective study in-
volving 186 children who received multiple halothane
anesthetics (for a total of 1362 operations), not one
case of post-operative jaundice occurred (Wark et al.
1986). Wark et al. (1991) performed a prospective
study in 38 children with biopsy-proven liver disease to
assess the effect of surgery and halothane anesthesia
on liver function. Minor elevations of liver enzymes
(both SGOT and SGPT) occurred in 4 patients, but
this was not associated with a clinical deterioration in
the patients’ postoperative recovery. As applied to
BMAs, the risks might be expected to be significantly
lower given the very brief induction and maintenance
periods required.
Fisher et al. (1985) assessed the efficacy of halothane
as compared to two other inhalation anesthetics (en-
flurane and isoflurane) for helping children who under-
went BMAs and lumbar punctures. In that study of 66
children (8 months to 18 years) and 124 procedures,
the total time from start of procedure to discharge
averaged 22.3 min for halothane, almost identical to
the other two agents. However, halothane demon-
strated the lowest incidence of excitement and cough-
ing. Incidence of laryngospasm was lower for both
halothane and enflurane and reportedly mild in al1
cases.
Although halothane appears to be a safe, reliable
and short-acting anesthetic agent with limited side
effects, more data is needed to determine if it is a
viable approach for children undergoing BMAs. Even
though halothane provides a pain-free BMA, children
and parents may not be without distress given that
some children find mask induction aversive and par-
ents may be concerned about the medical risks in-
volved. More research is needed to document the
following: (1) children’s emotional and behavioral re-
sponses to genera1 anesthesia; (2) its acceptability by
children, parents, and care-givers; (3) the intensity and
duration of side effects; and (4) tost-benefit considera-
tions, particularly in relation to more commonly used
psychological interventions.
In summary, the physician or nurse who administers
BMAs to children is faced with a dilemma of com-
pletely contrasting approaches for helping patients deal
with the trauma of these procedures: psychological
intervention with established but incomplete efficacy;
premedications with substantial and long-lasting side
effects; and genera1 anesthesia with its risks, costs, and
side effects. The purpose of this study is to compare
the efficacy of cognitive-behavior therapy (CBT) with
genera1 anesthesia (halothane) for pediatrie cancer pa-
tients undergoing BMAs.
Methods
Subjects
Eligible subjects included leukemia patients between the ages of
3 and 12 years whose medical protocol required at least 2 outpatient
BMAs within a 25month period.
Eighteen leukemia patients (9 boys and Y girls) completed the
study. The mean age of the sample was 5.9 years with a standard
deviation of 2.6 years. The ethnic composition was as follows: 7 were
Caucasian, 3 were English-speaking Latino; 5 were Spanish-speaking
Latino, 2 were Black; and 1 was Other. Twelve of the subjects were
newly diagnosed and were in their first 6 weeks of treatment, 5 were
in their first remission, and 1 subject was in remission after a recent
relapse.
Design
The study consisted of 2 experimental conditions, cognitive be-
havior therapy (CBT) and general anesthesia (GA) delivered in the
context of a repeated-measures counterbalanced design and subjects
were randomly assigned to 1 of 2 sequence orders.
Intervention
Cognitiue-behavior therapy
The CBT package consisted of filmed modeling,
breathing exercises, imagery/ distraction, positive in-
centive, and behavioral rehearsal. This intervention
took about 45 min to complete. The child was first
shown a video of another child receiving a BMA. In
this video, the child narrated the steps of the BMA
procedure, along with thoughts and feelings at critical
points. In addition, the child modeled positive coping
behavior (breathing exercises, imagery) and positive
coping self-statements (e.g., “1 know, 1 can do it”).
After the video, children were presented with a smal1
trophy as a symbol of bravery and courage, and the
award was contingent on the child doing “the best that
you possibly can”. Then they were taught a simple
breathing exercise. Each child was instructed to take a
deep breath and to let it out slowly while making a
hissing sound. Imagery strategies were developed with
each child by assessing what images the child liked
which would be incompatible with the experience of
pain (examples: Disneyland, eating pizza, Springstein
concert). Some children who liked superheroes were
helped to create a story which integrated the BMA
into a situation involving the superhero invoking themes

of mastery (for example, one child pretended that the
BMA was part of a special mission for agents on
Superman’s team). Children were given active guidance
during the BMA by the therapist to help them form
and maintain the images. Finally, behavioral rehearsal
involved a step-by-step administration of the BMA by
the child on a dol1 using the actual medical equipment.
Genera1 anesthesia
A blood test was conducted within 48 h prior to the
BMA procedure (i.e., CBC, platelet count, liver en-
zyme levels). Criteria for approval for anesthesia in-
cluded an absolute neutrophil count over 1000, a
platelet count over 50,000, and liver enzyme levels no
higher than twice the normal limit. One or both par-
ents were present throughout the administration of
anesthesia. Anesthesia was induced and maintained via
a face mask with nitrous oxide (60-70%) and halothane.
The concentration of halothane was adjusted as clini-
cally indicated to maintain light anesthesia but prevent
movement during the procedure. Devices used for
monitoring included a precordial stethoscope, electro-
cardiogram, Dinamap for blood pressure measure-
ment, and Nellcor for 0, saturation monitoring. An
oxygen sensor was placed in the inspiratory limb of the
breathing circuit.
Assessment instruments and procedures
Child measures
The Observational Scale of Behavioral Distress
(OSBD) ‘, an observation instrument with established
reliability and validity (Jay et al. 1983; Jay and Elliott
1984; Elliott et al. 1987;), was used to code behavioral
distress during the first 2 phases of the BMA in each
condition. The OSBD consists of 8 operationally de-
fined behaviors that indicate pain and anxiety and are
weighted according to severity of distress (cry, scream,
physical restraint, verba1 resistance, seeks emotional
support, information seeking, verba1 pain, flail). Sub-
jects were observed from the time they walked into the
procedure room until they were asked to lie down on
the treatment table (phase 1) and then for the 1st
minute after they laid down (phase 2).
Self-report measures of pain and fear
Self-reported fear and pain were assessed using
5point face scales where the faces depict varying levels
of pain and fear. In both the CBT and GA conditions,
the Fear Scale was administered to children as soon as
they were on the procedure table, just before the
TheBD is available by writing Susan Jay, Ph.D, 11500 W.
Olympic Avenue, Suite 380, Los Angeles, CA 90064, USA.
5
BMA. The Fear Scale was administered again (e.g.,
“How scared were you?“) along with the Pain Scale
approximately 15 min after leaving the treatment room.
Physiological measure
The child’s pulse rate was measured with a Di-
namap Model 845 as soon as he or she got on the
procedure table immediately before the procedure.
The Dinamap gave a digital readout of pulse rate after
60 sec.
Anticipatory anxiety of next BMA
Children’s fear of their next BMA was assessed with
the Fear Faces Scale about 30 min after the procedure.
Liver enzyme assessment
Three to 5 days after the genera1 anesthesia, a blood
test to assess liver enzyme levels was administered to
determine any possible liver toxicity resulting from the
halothane. Specifically, SGPT, SGOT, alkaline phos-
phatase, and total bilirubin were measured.
Side effects evalua tion
Following the BMA in the genera1 anesthesia condi-
tion, the presence or absente of the following side
effects were recorded on the Side Effects Evaluation
Sheet: nausea, vomiting, dizziness, headache, fever,
jaundice and ‘other’. Side effects were noted on a 1-4
scale of severity. The Side Effects evaluation was con-
ducted 30 min after the BMA and then once every
hour by an observer until the child’s discharge from the
clinic, usually 4-6 h later.
Post-Procedure Parent Questionnaire of behavioral ad-
justment (PPQ)
Twenty-four hours following the child’s BMA, par-
ents were telephoned or interviewed in the clinic and
asked to report on the presence or absente of a variety
of emotional and behavioral indices of adjustment us-
ing the Post-Procedure Parent Questionnaire (PPQ) of
behavioral adjustment designed by the investigators.
This measure was developed along the lines of the
Post-Hospita1 Behavior Questionnaire (Vernon et al.
1966) which has been widely used to document chil-
drens’ reactions to surgery and hospitalization. The
indices measured included: sleep difficulties, low activ-
ity and lethargy, irritableness, nervousness, behavior
problems, withdrawal, and appetite difficulties.
Parent assessment measures
Observational Scale of Parent Affective Expression
(OSPAl
The OSPAE was developed by Pruitt et al. (1989) to
assess parents’ affective facial and behavioral expres-
 6
sions during their child’s BMA. The OSPAE consists
of 2 categories of positive affective expressions (smile
and laugh) and 7 categories of negative affective ex-
pressions (sigh, headshake, wince, facial tension, frown,
avoidance, and tears) which were coded for presence in
15sec intervals by an observer.
Anxiety
Parents’ leve1 of anxiety was assessed by the admin-
istration of the State version of the Spielberger State
Trait Anxiety Inventory (SSTAIXSpielberger et al.
1970) prior to entering the treatment room. They were
also asked to complete a 7-point Likert-scale of anxiety
with 1 = not anxious at al1 and 7 = extremely anxious.
Physiological measures
The IVAL Vita1 Check 4000 was used to collect the
parent’s pulse rate quickly and non-intrusively during
phase 1 of the child’s Bh4A procedure.
Self-reported coping difficulty
A measure of coping difficulty by the parent was
obtained immediately following the BMA using a 5-
point Likert Scale.
Expectancy
Expectations of parents towards each type of inter-
vention were measured by asking them at the begin-
ning of each condition to code on a 7-point ‘expected
helpfulness’ scale.
Nurse /physician assistant assessment measures
The pulse of the nurse or physician’s assistant who
conducted the BMA was taken just prior to the BMA
and he/she was asked to rate bis/ her leve1 of ‘stress’
on a 7-point Likert Scale. After the BMA, the nurse or
physician assistant was asked to rate on a 7-point
Likert Scale, the leve1 of difficulty he/she had in
conducting the BMA and the leve1 of stress experi-
enced during the procedure.
Consumer preferente
The preferente of patients and their parents for
either genera1 anesthesia or CBT was assessed shortly
after subjects had completed both conditions of the
study.
Results
Reliability of OSBD
Interrater reliability checks for the behavioral obser-
vations were conducted for 22% of the procedures. A
Pearson product-moment correlation analysis con-
ducted between observers’ OSBD scores yielded an
r = 0.98. The agreement-disagreement method also was
used to calculate reliability, yielding a mean percent
agreement of 90%, with a range from 82 to 100%.
Admittedly, the reliability data represent a smal1 num-
ber of subjects, but the OSBD has consistently been
demonstrated as highly reliable in several previous
studies with iarger numbers (Elliott et al. 1987; Jay et
al. 1991).
Reliability of OSPAE
Interrater reliability checks were conducted for 28
percent of the procedures. A Pearson product-moment
correlation analysis conducted between observers’ posi-
tive and negative OSPAE scores yielded an r of 98%
and 99%, respectively. As with the OSBD, the agree-
ment-disagreement method was also used to score the
agreement of the observers as to whether the OSPAE
categories occurred. Results indicated a mean of 91%
(range: 85-98%).
Sequence effects
Since subjects were randomly assígned to a se-
quence order ín whích they would receíve the 2 inter-
vention condítions, 2 X 2 repeated-measures ANOVAS
were conducted wíth each dependent varíable to deter-
míne if any Sequence X Intervention ínteractions were
present. NO significant Sequence x Intervention inter-
actíons were found.
Child distress outcome measure
Paired t tests were conducted to determíne díffer-
ences between the CBT and GA condítions on the
following variables: OSBD scores (phases 1 and 2);
pulse rate; antícipatory fear; ‘scared’ ratíngs after the
procedure; pain ratings; fear of next procedure; and
PPQ scores. The experimenter-wise error rate was
adjusted by the number of t tests performed. This
resulted ín an alpha leve1 of 0.007.
Significant dífferences were found on only 2 mea-
sures: OSBD phase 2 scores (t = 3.71, df = 17, P =
0.002) and PPQ scores (t = 3.05; df = 17, P = 0.007).
Results indícated that children exhíbited more behav-
ioral dístress in the CBT condítion for the 1st mínute
after lyíng down on the treatment table (mean: 2.8,
SD = 3.0) than when in the GA condítion (mean: 0.13,
SD = 0.45). Parents rated signifícantly more behavioral
adjustment symptoms for their chíldren wíthín the 24-h
period followíng the BMA after their chíldren were in
the GA conditíon (mean: 0.72, SD = 1.13) than when
they were in the CBT condition (mean: 0.11, SD =
0.47). Inspection of the raw data índicated that only 1
chíld exhíbíted symptoms after the CBT condítíon (be-
havior problems and irritabílíty) whíle 8 chíldren had
one or more symptoms after the GA condítíon. After
the GA condítion, 2 were withdrawn, 2 were irrítable, 1
was anxious, 1 was lethargie, 1 exhíbíted lethargy, with-

drawal, appetite difficulties, and irritability, and 1 ex-
hibited appetite difficulties, tiredness, and withdrawal.
Liver enzyme measures
Results of the bloed tests indicated that 4 of the 18
patients had transient elevations of SGOT and SGPT
post-anesthesia. SGOT or SGPT remained elevated for
1-3 weeks for 3 patients and 2.5 months for 1 patient.
Side effects from anesthesia
One child experienced mild to rnoderate nausea and
vomiting within the first 2 h after the BMA, 3 experi-
enced mild dizziness after the procedure which lasted
for less than 2 h, and 1 child experienced a mild
headache for 2 h afterwards. NO child exhibited fever
or jaundice. Sixteen of the 18 children were able to eat
and drink within 1 h after anesthesia and al1 18 sub-
jects were eating and drinking within 2 h after the
BMA.
Parent outcome measures
Paired t tests were conducted for the following
measures: pulse rate just prior to the procedure, SSTAI
ratings, Likert anxiety ratings, expectancy ratings, cop-
ing difficulty ratings, and OSPAE scores.
Results indicated significant differences between the
GA and CBT condition for only 1 variable, expectancy
ratings (t = -2.33, df = 16; P = 0.033). Parent’s expec-
tations of helpfulness were higher for the GA condi-
tion (mean: 6.3, SD = 78) than for the CBT condition
(mean: 5.2, SD = 1.6). However, this result was not
considered significant when using the adjusted experi-
menter-wise error rate (P = 0.008) necessitated by mul-
tiple t tests.
Nurse /physician-assistant outcome measures
Results of paired t tests indicated significant differ-
ences on 1 variable: nurse/PA ratings of their stress
levels prior to the BMA (t = - 2.61, df = 17, P = 0.02).
The nurse/ PA indicated higher levels of stress prior to
the BMA in the GA condition (mean: 2.0, SD = 1.3)
than prior to the BMA in the CBT condition (mean:
1.3, SD = 57). This result was not considared signifi-
cant when using the adjusted error rate, (P = 0.01251,
necessitated by multiple t tests.
Consumer preferente
Forty-two percent of the children who responded
after completion of both conditions reported that they
preferred CBT compared to 58% who preferred GA.
Forty percent of the parents who responded preferred
CBT as compared to 56% who preferred GA. A l-sam-
ple chi-square analysis indicated that these differences
were not significant.
7
Predictive factors of consumer preferente
The issue of matching the appropriate intervention
to any given child has been of interest to the authors so
the question arises, what factors predict a child or
parents’ preferente for CBT versus GA? Although our
sample size was smal1 and precluded more sophisti-
cated regression analyses, t tests were run to deter-
mine possible predictive factors. Preferente for CBT or
GA was the independent variable and the following
were dependent variables: child’s age, number of previ-
ous BMAs, months since diagnosis, and OSBD scores
in each intervention. Results yielded no significant
effects. A chi-square was conducted using sex of child
as the dependent variable and again, no significant
effects on preferente were found.
Time required to conduct interventions
In considering tost/ benefit differences between
genera1 anesthesia and CBT, the time required to
conduct each intervention was measured and com-
pared. The mean time from entrance into the proce-
dure room until leaving the room was 11 min for the
CBT condition versus 30 min for the GA condition.
This differente was statistically significant (t = - 7.73,
df = 14, P = 0.001).
Discussion
Results of this study were surprisingly equivocal.
With respect to the child outcome measures, no signifi-
cant differences on self-reported pain and fear, pulse,
or anticipation of the next BMA were found in relation
to CBT versus genera1 anesthesia. Children did exhibit
more behavioral distress in the CBT condition for the
first minute after lying down on the treatment table
than when they were about to receive genera1 anesthe-
sia. In the genera1 anesthesia condition, the mask was
placed on the child within this time period; thus, it
appears that children did not exhibit much distress in
relation to the placement of the mask. It may also be
that children were less distressed prior to the genera1
anesthesia because they knew they were not going to
experience pain during the BMA.
Side effects of the genera1 anesthesia soon after the
procedure were quite minimal, especially when com-
pared to commonly used premedications mentioned
previously. A particularly interesting finding was that
24-h post-procedure, parents reported significantly
more behavioral adjustment symptoms after the GA as
compared to the CBT condition.
The data collected in relation to parental stress and
coping also demonstrated virtually no differences be-
tween CBT and GA. There was a slight trend toward
8
parents favoring genera1 anesthesia in terms of their
expectations of helpfulness but measures reflecting
their distress and coping during and after the proce-
dure were not significantly different. It may seem sur-
prising that parents did not experience more difficulty
coping when their child received no anesthesia (nor
any premedication). However, the risks associated with
genera1 anesthesia may have been on parents’ minds
and several parents noted that under genera1 anesthe-
sia, their child lay so inert that they were reminded of
and haunted by the risks mentioned in the consent
form (brain damage and death).
In fact, the authors speculate that the process of
informed consent may have contributed significantly to
parental anxiety about genera1 anesthesia, thus coun-
teracting or balancing out the obvious benefits, and
contributing to the difficulty in obtaining a larger sam-
ple of subjects. Since this was a research study, parents
were warned of the risks of genera1 anesthesia in vivid
bold detail on the consent form. If anesthesia were
presented solely in a clinical context, the risks would
not generally be explained in such detail which limits
the external validity or generalizability of our current
findings.
Although the nurse and the physician’s assistant
who administered the BMA demonstrated a slight trend
toward increased anxiety in relation to genera1 anes-
thesia, this finding was non-significant and seemed to
be related to their lack of experience with genera1
anesthesia in an outpatient setting.
Consumer preferente was not significantly different
between the two conditions for children or their par-
ents. A power calculation was conducted to determine
if the lack of statistical significante would persist with a
larger sample size. The results indicated that one would
need a sample size of 120 subjects for the ló-point
differente in preferente scores to be significant. Fur-
thermore, no predictor variables were discovered which
could suggest which children would benefit most from
which intervention. Unfortunately, the relatively smal1
sample size was a distinct disadvantage in this regard.
It appears clear at this time that genera1 anesthesia
was a popular but not universally preferred option.
Results of the post-anesthesia blood tests indicated
that 4 of 18 patients demonstrated abnormally elevated
liver enzyme levels, again raising the question of
whether halothane is hepatotoxic. Al1 4 of the patients
with elevated SGOT and SGPT after anesthesia had
received intrathecal methotrexate in addition to L-
asparaginase during their chemotherapy course prior
to anesthesia as wel1 as mercaptopurine afterwards,
and these chemotherapeutic agents are known to be
hepatotoxic (Haskell et al. 1969; Roenigk et al. 1988;
Selvin 1981). However, a review of the patient charts of
al1 18 patients indicated that many of the patients
whose liver enzymes were not elevated after anesthesia
also had received equal or higher doses of these
chemotherapeutic drugs. It cannot be determined
whether the hepatoxicity represents an adverse reac-
tion to the chemotherapy, or to the genera1 anesthesia,
or to a synergistic combination of the two. Controlled
studies with a larger sample size are needed to further
investigate the effects of halothane, chemotherapy, and
possible interactions of these agents for pediatrie can-
cer patients.
The findings in this study pertain most directly to
mask halothane anaesthesia and may not generalize
with other methods. Propofol, which was not available
at the time of this study, is probably more commonly
used now because the incidence of nausea is less and it
can be induced intravenously with children who have
indwelling lines (Morton et al. 1992). However, a re-
cent report indicates the possibility of delayed seizures
after propofol anaesthesia (Finley et al. 19931, suggest-
ing that further research is necessary to determine its
safety and clinical usefulness.
The implications of this study for clinical practice
must be considered. The authors conclude from the
results of this study that both psychological interven-
tion and genera1 anesthesia should be viable alterna-
tives offered to patients and their parents. This conclu-
sion is consistent with the recommendation made by
Zeltzer et al. (1990) in their report of the Subcommit-
tee on the Management of Pain Associated with Proce-
dures in children with Cancer in which specific guide-
lines and principles of pain management are recom-
mended and detailed. Ideally, children could be
matched to the most appropriate intervention for them
based on predictive factors such as age, coping style, or
preference,(an area in need of future research), or
children could receive psychological intervention as
preparation for the BMA in conjunction with anesthe-
sia or pharmacologic intervention as recommended by
Zeltzer et al. (1990). Administration of BMAs with no
psychological or medical intervention is no longer ac-
ceptable practice given the data on distress and pain in
children undergoing these procedures as wel1 as the
data on effective intervention.
Acknowledgements
This study was supported by a grant from the Na-
tional Cancer Institute, National Institute of Health, to
Susan Jay.
We thank Bob Miller, Barbara Britt, and Alice Loo
who helped to administer BMAs; Ed Scott, Rukays
Hamid, and Rigoberto Segura for assistance in admin-
istering anesthesia; and Mark Harrold, Miguel Loren-
zana, Laurie Schoellkopf, Kay Ceeske, and Angelita
Diaz-Akahori for data collection.

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