Enhancing Pain Management in the PICU by Teaching Guided

Mental Imagery: A Quality-Improvement Project

William H. Kline,1 PHD, Ayme Turnbull,2 PSYD, Victor E. Labruna,2 PHD, Laurie Haufler,3 RN,
Susan DeVivio,3 RN, NP and Peter Ciminera,3 MD
1
Division of Child Psychiatry, North Shore-LIJ Health System, 2Division of Trauma Psychiatry, North Shore-LIJ
Health System and 3Department of Pediatrics, Nassau University Medical Center

Objective This quality-improvement study, following the PDCA methodology, compared the effectiveness of
teaching mental imagery (MI) for pain management versus conducting a detailed inquiry (DI) about pain-related
experiences with acutely injured PICU patients. Methods Participants included 44 hospitalized children
and adolescents assigned to one of two intervention groups, MI (N ¼ 24) or DI (N ¼ 20). Pain was assessed pre-
and post-intervention using the Wong-Baker Faces Pain Rating Scale and a 0–10 Likert pain rating scale, and the

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on April 23, 2013

Pediatric Trauma Score was utilized to assess the severity of each child’s injuries. Results Boys in the MI
condition exhibited a significant decrease in average pain ratings [t(38) ¼ 3.41, p ¼ .0015]. Girls in the MI
condition exhibited a non-significant decrease in average pain ratings. Conclusions Teaching children the
use of MI for pain management in an intensive-care setting was supported; the use of DI with boys was not
supported.

Key words accidents and injuries; children; coping; pain.

Research has shown that pediatric pain is not treated
as comprehensively and attentively in children as it is
in adults, in part because of the slow translation of
empirical knowledge into routine clinical practice
(Howard, 2003; Schechter, 1989). Despite the fact that
non-pharmacological pain treatment procedures have
been cited as promising in the effort to reduce pediatric
pain (Lassetter, 2006), pre-surveys conducted with the
staff of the pediatric intensive care unit (PICU) of a sub-
urban level-I trauma medical center at which the current
study was conducted indicated that there was much about
non-pharmacological pain treatment options, procedures,
and effectiveness that physicians did not know. Physicians
in particular tended to believe that children did not expe-
rience pain in the same way adults do and as such tended
to minimize their pain.
Numerous negative outcomes of inadequate pain man-
agement among children have been cited in the literature,
including long-term behavioral changes, pain-perception
impairment, pain-tolerance reduction, physical disability,
and emotional disability (Howard, 2003). Inadequate pain
management may be particularly detrimental to children
and adolescents facing life-threatening injury or illness on
a PICU, as well as to the parents of such children and
adolescents. According to Turner (2005), ‘‘pain negatively
impacts physiologic responses of nearly every body system,
potentially contributing to hemodynamic, respiratory,
metabolic, and neurological instability. Parents, already
overwhelmed by the high-tech environment of the PICU,
feel even more helpless and distressed when they see their
child’s discomfort’’ (pp. 388–389).
The PICU pain-management quality-improvement
(QI) initiative, of which the current study was a part,
was begun in response to patient complaints about pain
and the observation of the staff that the unit’s current
methods of pain control were inadequate and involved
painful procedures (e.g., injections, IV pushes). Over the
course of the QI initiative, which employed the PDCA
methodology (Plan, Do, Check, Act), three different non-
pharmacological interventions were implemented for pain
management in PICU patients: distraction, detailed
inquiry (DI), and teaching guided mental imagery (MI).

All correspondence concerning this article should be addressed to William Kline, PhD, 103 Huntington Rd,
Port Washington, NY 11050, USA. E-mail: billkline9@aol.com
Journal of Pediatric Psychology 35(1) pp. 25–31, 2010
doi:10.1093/jpepsy/jsp030
Advance Access publication April 22, 2009
Journal of Pediatric Psychology vol. 35 no. 1 ß The Author 2009. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org
26 Kline et al.
Distraction is one of the most essential, if not the
most essential, element of psychological pain-reduction
interventions for young children in distress (MacLaren &
Cohen, 2005) and was an essential component of an early
successful non-pharmacological pediatric pain manage-
ment study (Elliott & Olson, 1983). For these reasons,
it was selected as the first intervention for the PICU QI
initiative. Psychological debriefing was a popular post-
trauma intervention in the late-1990s (for evidence, see
Moran, 1998), and neither its modification to DI regarding
pain-related experiences nor its implementation required
extensive additional staff training; for these reasons, it was
employed during the second PDCA cycle of the PICU QI
initiative. Teaching MI for pain management in children
was supported, at the time when the third PDCA cycle
of the PICU QI initiative began, by Powers (1999) who
reviewed 13 published outcome studies of empirically-
supported psychological treatments for pediatric pain
related to medical procedures and found that CBT techni-
ques, including but not limited to MI, comprised the only
‘‘well-established treatment’’ for procedure-related pain in
children and adolescents. MI has been shown to be effec-
tive in cases of pediatric functional abdominal pain (Ball,
Shapiro, Monheim, & Weydert, 2003; Youssef et al., 2004)
and after surgery (Lambert, 1996; Martz Huth, Broome, &
Good, 2004), in addition to during a variety of painful
medical procedures (Martz Huth et al., 2004).
Although a few studies have examined the efficacy of
psychological approaches to pediatric pain management
with injured children in hospital settings (Elliott &
Olson, 1983; Tanabe, Ferket, Thomas, Paice, &
Marcantonio, 2002), there is a relative lack of studies
that address the need for and efficacy of brief, easily
taught and learned, ‘‘real-world’’ psychological and
complementary-therapy interventions for pain reduction
in injured children (see Lassetter, 2006 for a review of
the documented use of complementary therapies for
hospitalized children), and little is known about the effec-
tiveness of guided MI as a pain-reducing distraction
technique specifically for children and adolescents with
serious medical conditions. Despite this, MI remains an
appealing non-pharmacological intervention for children
because of its simplicity and potential to enhance a
child’s sense of self-efficacy in managing his or her pain
(Dillard & Knapp, 2005). For the above reasons, in
addition to its painlessness, the PICU staff selected MI as
the cognitive-behavioral pain-management intervention to
teach patients during the third PDCA planning phase of its
QI initiative.
The third PDCA cycle was begun after the interven-
tions piloted in the first and second PDCA cycles fell short
of eradicating pain and were found to be cumbersome to
implement. When videos and video games were made
available as distractions from pain during the first PDCA
cycle of the QI initiative, patients’ pain medication use was
rated by staff as having increased, decreased or remained
constant. Although 56% of patients used less medication
over time while videos and video games were available to
them on the PICU, 30% of patients used more medication,
and there were no baseline data for comparison. In addi-
tion, purchasing new videos and video games was costly,
and managing the required technology was time-
consuming for staff nurses. The use of DI during the
second PDCA cycle was not experienced by PICU staff as
burdensome and led to self-reported pain reductions in
36% of patients, but this pain-reduction rate seemed
inadequate compared to the results achieved during the
Downloaded from http://jpepsy.oxfordjournals.org/ by guest on April 23, 2013
first PDCA cycle. The current study, based on the results
of the third PDCA cycle which employed a much more
rigorous assessment protocol, compares the effectiveness
of teaching MI to the effectiveness of DI.
Hypotheses
It was predicted that there would be a significantly greater
average reduction in pain ratings among participants who
were taught to employ MI as a means of pain management
compared to participants who participated in the DI
condition and were not taught MI techniques. Based on
literature indicating that boys and girls may have different
preferences for emotion-focused versus active coping tech-
niques (Keogh, Hatton & Ellery, 2000; Recklitis & Noam,
1999; Spirito, Stark, Gil & Tyc, 1995), there was a second-
ary, exploratory hypothesis that gender would interact
with treatment condition.
Method
The current study was conducted as an archival analysis of
data collected between 1999 and 2001 for a QI initiative on
the PICU of a large suburban public hospital in response to
ongoing patient complaints about pain and the observation
of the PICU nursing staff that the unit’s current methods of
pain control were not sufficient and involved painful pro-
cedures (e.g., injections, IV pushes). Institutional Review
Board (IRB) approval of the protocol was obtained from the
hospital at which the study was conducted.
Participants
Participants included 44 children who were admitted
to the hospital PICU from the hospital’s Emergency

Department between 1999 and 2001. In 2001, the princi-
pal investigator left the hospital and no further participants
were enrolled in the study. Participants included 20
females and 24 males with a mean age of 13.5 years and
a range of 6–18. All participants were English-speaking,
and victims of non-intentional injuries. Participants came
from a wide socioeconomic status range. The rates of
injury causes and types were as follows: In the MI group,
46% of the participants were struck by automobiles, while
50% had closed head injuries related to being a passenger
in a motor vehicle accident (MVA), and 4% had other
physical injuries from an MVA. In the DI group, 40%
were pedestrians struck by automobiles, while 60% had
closed head injuries as a result of being a passenger in
an MVA. Because burn victims were treated on a separate
medical unit, no burn victims were included in the sample.
The mean length of stay on the PICU was 5.34  3.84
days, with a range of 2–21 days.
Twenty participants, including 11 girls and 9 boys,
were included in the DI condition and 24 participants,
including 9 girls and 15 boys, were included in the MI
condition. See Table I for a breakdown of demographic
characteristics, mean length of stay, pediatric trauma
scores, and baseline pain ratings for participants in the
MI and DI groups. There were no statistically significant
group differences on any of these variables.
Recruitment
Potential study participants were initially identified by
PICU nursing staff. To determine actual study eligibility,
study staff inquired about the nature of each potential
Table I. Selected demographic variables by group
Variable DI (n ¼ 20)
Age, mean (SD) 13.8 (2.9)
Sex, n (%)
Female 11.0 (55)
Male 9.0 (45)
Race, n (%)
White 10 (50)
African-American 6 (30)
Hispanic 3 (15)
Asian 1 (5)
Other 0 (0)
Insurance status, n (%)
Medicaid, no insurance 6 (29)
Private insurance 15 (71)
Length of stay, mean (SD) 4.7 (2.3)
Baseline pain ratings, mean (SD) 4.45 (2.9)
Pediatric trauma score, mean (SD) 9.2 (2.0)
Note. Percents may not add to 100 due to rounding.
Mental Imagery for Pediatric Pain 27
participant’s injury or illness and reviewed the child’s
chart to determine whether the child’s injuries met the
inclusion criterion of being moderate to severe as deter-
mined by his or her Pediatric Trauma Score on admission
to the PICU (scores between 5 and 12).
Measures
Pain rating scales were employed, including the 0–10 Likert
pain rating scale for children ages 8 and older and
the Wong-Baker Faces Pain Rating Scale for children ages
3–7 (Wong & Baker, 1988). The 0–10 Likert pain rating
scale (0 ¼ no pain, 10 ¼ worst pain) is a commonly used
psychometric pain reporting instrument that is considered
reliable and valid (Breivik, Bjornsson, & Skovlund, 2000),
as is the Wong-Baker Faces Pain Rating Scale for use with
verbal children (Keck, Gerkensmeyer, Joyce, & Schade,
Downloaded from http://jpepsy.oxfordjournals.org/ by guest on April 23, 2013
1996). The Wong-Baker faces range in expression from
happy to extremely pained.
The Pediatric Trauma Score (Tepas, Mollitt, Talbert, &
Bryant, 1987) was utilized to assess the severity of
each child’s injuries. The Pediatric Trauma Score is an
established and highly-reliable means of assessing the
severity of injuries in children (Ramenofsky et al., 1988;
Tepas, Veldenz, Discala, & Pieper, 1997) and is calculated
based on evaluations of respiration, alertness, systolic
blood pressure, estimated body weight, and the presence
and severity of soft tissue injuries and fractures, each of
which is scored between 1 and þ2 (lower scores indicate
greater trauma severity). Scores less than nine points
are considered to indicate a potentially life-threatening
situation (Tepas et al., 1987).
Interventions
Teaching Mental Imagery
MI (n ¼ 24) MI exercises were developed by study staff in response
13.3 (3.64) to the plan developed during the planning stage of the
third PDCA cycle. As is recommended by Alden, Dale, &
9.0 (37.5) DeGood (2001), participants were encouraged to employ
15.0 (62.5) pleasant imagery as distraction from pain. The protocol
was brief to accommodate the needs of the setting in
9 (38) which the study was conducted. Participants were first
5 (21) instructed to relax and were led through an exercise
9 (38)
during which they were to imagine a light of their favorite
0 (0)
color shining on a painful part of their bodies and remov-
1 (4)
ing the pain; the imagery was thus focused both externally
9 (39)
and internally, which is common in real-world clinical
14 (61) practice despite the recommendation that mental imagery
5.88 (4.8) be internally focused for maximum efficacy (Alden et al.,
5.3 (2.5) 2001). Participants were then instructed to imagine their
9.0 (2.0) favorite object (e.g., a toy or a pet) and their favorite expe-
rience (e.g., playing/hanging out with friends, being at the
28 Kline et al.
beach, or being at a toy store) and were encouraged to
continue utilizing these techniques for pain management.
Conducting a Detailed Inquiry
At the time of the current study, DI in the tradition
of critical incident stress debriefing was the most recent
intervention employed as part of the QI initiative. Although
there is significant variability in the actual practice of
conducting inquiries regarding patients’ pain-related
experiences, the DI condition in the current study involved
the following activities: detailed inquiry about a patient’s
current pain-related experiences, providing an opportunity
for the patient to express his or her thoughts and feelings,
active listening, reflecting and reframing the person’s ver-
balizations, providing information, and providing comfort.
Study interventionists were trained, under supervision by
the primary investigator, to elicit participants’ descriptions
of their experiences of the accidents in which they were
involved as well as their subsequent pain-related experi-
ences, particularly those related to their medical treatment.
Interventionists were also trained to elicit participant
descriptions of thoughts and feelings experienced during
an accident, during medical interventions, and at the time
of participation in the study. Effort was made by study
interventionists to provide support and to normalize
common reactions. No experimenter script was used in
this condition.
Procedure
Within 24 h of a conscious, extubated, and verbal child’s
admission to the PICU through the hospital’s Emergency
Department, nursing staff contacted the study team at the
Pediatric Psychology Consultation and Liaison Service.
Once a child was determined to meet criteria for entrance
into the study, consent was requested from the legal guar-
dian. Children aged 14 and older were asked for their
written assent before entry into the study.
Participants were assigned to one of the two partici-
pant groups based on whether they were admitted to the
PICU on an odd-numbered day or an even-numbered day.
It should be noted that, in the QI project from which these
data come, perfect participant randomization was not a
priority. Prior to participating in the MI or DI protocol,
study staff, comprised of the first author and graduate
students in clinical psychology, administered the appropri-
ate self-report pain rating scale based on a participant’s
age and obtained demographic, injury severity, and pain
medication use information from PICU staff and from the
participant’s medical record. In an effort to minimize the
influence of relatively recent painful procedures, partici-
pants were asked to rate their pain since their arrival on
the PICU unit. Once the above information was obtained,
participation in the MI and DI protocols took place in a
single session at bedside on the PICU. Participation was
led by a member of the study staff and lasted 15–20 min.
Within 48 h, each child/adolescent was re-evaluated
using the same assessment procedure as above (pain was
assessed ‘‘since the last time we talked’’). These follow-up
assessments included, for participants in the MI condition,
an inquiry about participants’ use of the MI techniques
and their usefulness in reducing pain.
Statistical Analysis
Changes in pain data were analyzed using a 2 (group)  2
(gender)  2 (time) repeated-measures mixed-factorial
ANOVA design. In order to further examine differences
between treatment groups, pairwise comparisons (t-tests)
Downloaded from http://jpepsy.oxfordjournals.org/ by guest on April 23, 2013
were utilized to examine differences between groups that
exhibited decreases in pain ratings and those groups that
exhibited increases in pain ratings. Finally, as a descriptive
measure, the proportion of participants in each group
whose pain ratings increased between baseline and
follow up was calculated.
Results
The following results constitute the check phase of the
third PDCA cycle. Means and standard deviations for the
pre- and post-intervention pain ratings of boys and girls in
the MI and DI groups are presented in Table II and
depicted graphically in Figure 1. Mean pain ratings
decreased among both girls and boys in the MI condition
(particularly for boys) and among girls in the DI condition.
However, mean pain ratings increased among boys in the
DI condition. A boxplot (Figure 2) depicting the changes in
pain scores provides additional information regarding
gender and group differences. The boxplot again indicates
that boys in the mental imagery condition appeared to
benefit the most. Girls in both conditions exhibited some
Table II. Mean Pre- and Post-Intervention Pain Assessment Scores for
Male and Female Participants in the DI and MI Conditions
Pre-Intervention Post-Intervention
Condition n Mean SD Mean SD
DI
Boys 9 4.56 2.83 5.33 2.50
Girls 11 4.36 2.92 3.00 3.38
MI
Boys 15 5.46 2.27 3.26 2.54
Girls 9 5.22 3.19 4.55 3.21
 Mental Imagery for Pediatric Pain 29

6.5
participants [t(38) ¼ 3.41, p ¼ .0015]. The decreases in
6 mean pain ratings between baseline and follow-up for
female participants in the MI and DI conditions were not
5.5
Inquiry boys
statistically significant.
5 In order to qualitatively examine the number of
Mean pain score

participants whose pain ratings worsened, the proportion

4.5
Imagery girls
of participants in each group whose pain ratings increased
4 between baseline and follow-up were calculated. In the DI
3.5
condition, four of nine boys (44%) and 4 of 11 girls (36%)
Imagery boys
reported an increase in pain ratings. There were fewer
3
Inquiry girls participants reporting increased pain scores in the MI
2.5
condition; 2 of 15 boys (13%) and two of nine girls
Pre-Intervention Post-Intervention
(22%) reported increases in pain ratings over time.
Figure 1. Change in pain scores for boys and girls in the DI and MI T-tests were used to compare the participants in the
conditions. DI condition who reported increased pain levels over time
with all other participants. There were no significant differ-

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on April 23, 2013

ences in age, trauma severity, or use of pain medication
8.0
between DI participants whose average pain ratings
increased and all other subjects. However, there was a
6.0
trend [t(41) ¼ 1.68, p ¼ .10] towards lower baseline
4.0 pain ratings among the DI participants who reported
Baseline to Followup Change

increased pain at follow-up (M ¼ 3.5, SD ¼ 2.2) compared

2.0
0.0
–2.0
–4.0
–6.0
–8.0
Boys Inquiry Girls Inquiry
Group
Figure 2. Change in pain scores by gender and intervention group.
improvement in pain scores, although girls in the DI had a
greater range of responses, including more girls who pain
ratings worsened. The boxplot indicates that the majority
of boys in the DI faired the poorest, with most pain scores
either not changing, or actually worsening over time.
The repeated-measures ANOVA revealed a significant
three-way interaction among group, gender, and time,
F(1, 39) ¼ 5.52, p ¼ .024, 2 ¼ 0.10. Further analysis of
simple effects revealed a significant change in pain ratings
between baseline and follow-up for participants in the MI
condition [t(38) ¼ 2.66, p ¼ .01] but not among partici-
pants in the DI condition. Follow-up analyses for the MI
condition indicated that pain ratings decreased sig-
nificantly between baseline and follow-up for male
to other participants (M ¼ 5.23, SD ¼ 2.7).
25th Percentile
Minimum
Mean
50th Percentile
Maximum
75th Percentile
Discussion
The current study indicates that teaching the use of MI is
a more effective pain intervention for injured boys on a
PICU than is conducting a DI. Boys who were taught
MI techniques evidenced a significant reduction in self-
Boys Imagery Girls Imagery
reported pain ratings over time compared to boys in the
DI condition whose average pain ratings actually increased
over time. Girls in both the MI and DI conditions
evidenced decreases in average self-reported pain ratings
over time. However, 36% of girls in the DI condition expe-
rienced an increase in pain ratings. Because injured boys
benefited from being taught MI for pain management and
because teaching MI to injured girls was not contraindi-
cated by the results of the current study, teaching MI to
both boys and girls who are experiencing pain related
to traumatic injury is recommended if only one non-
pharmacological pain intervention can be implemented
on a PICU.
The above conclusion led the medical and nursing
staff of the Department of Pediatrics of the hospital
at which the study was conducted to implement a new
training protocol for all current and future PICU nurses,
medical residents, and fellows, to teach them how to
instruct patients in the use of MI for pain management.
While in many QI projects the action phase is meant to
30 Kline et al.
perfect an intervention based on obtained results, in the
third PDCA cycle of the present QI initiative, the result of
teaching the use of MI to PICU patients was so positive
that the action phase involved implementing the teaching
of MI as standard treatment on the PICU. In addition, as a
result of the current QI initiative, the hospital’s psychiatric
liaison and consultation service eliminated DI as a compo-
nent of treatment-as-usual during psychiatric consultations
on the PICU.
Limitations and Suggestions for Future Research
Limitations of the current study include the relatively small
number of participants, the lack of follow-up evaluation
beyond participants’ stays in the PICU, the lack of PICU
patient pain assessment once MI became the standard
treatment, and the lack of standardization of the DI con-
dition. Furthermore, there is a potential confounding effect
of pain medication which was not consistently measured
during the study. It is possible that differences existed in
the types and dosages of pain medications administered to
participants in the MI and DI groups. It is also of note that
there was no significant difference found in pain-rating
changes between girls in the MI and girls in the DI condi-
tions; this limits the strength of the conclusion that MI
is the preferred non-pharmacological pain intervention
for girls.
Conflicts of interest: None declared.
Received August 30, 2008; revisions received March 20,
2009; accepted March 21, 2009
References
Alden, A. L., Dale, J. A., & DeGood, D. E. (2001).
Interactive effects of the affect quality and directional
focus of mental imagery on pain analgesia. Applied
Psychophysiology and Biofeedback, 26, 117–126.
Ball, T. M., Shapiro, D. E., Monheim, C. J., & Weydert, J.
A. (2003). A pilot study of the use of guided imagery
for the treatment of recurrent abdominal pain in
children. Clinical Pediatrics, 42, 527–532.
Breivik, E. K., Bjornsson, G. A., & Skovlund, E. (2000).
A comparison of pain rating scales by sampling from
clinical trial data. Clinical Journal of Pain, 16, 22–28.
Dillard, J. N., & Knapp, S. (2005). Complementary and
alternative pain therapy in the emergency department.
Emergency Medicine Clinics of North America, 23,
529–549.
Elliott, C. H., & Olson, R. A. (1983). The management of
children’s distress in response to painful medical
treatment for burn injuries. Behaviour Research and
Therapy, 21, 675–683.
Howard, R. F. (2003). Current status of pain management
in children. The Journal of the American Medical
Association, 290, 2464–2469.
Keck, J., Gerkensmeyer, J., Joyce, B., & Schade, J. (1996).
Reliability and validity of the FACES and Word
Descriptor scales to measure pain in verbal children.
Journal of Pediatric Nursing, 11, 368–374.
Keogh, E., Hatton, K., & Ellery, D. (2000). Avoidance
versus focused attention and the perception of pain:
differential effects for men and women. Pain, 85,
225–230.
Lambert, S. A. (1996). The effects of hypnosis/guided
imagery on the postoperative course of children.
Journal of Developmental and Behavioral Pediatrics, 17,
Downloaded from http://jpepsy.oxfordjournals.org/ by guest on April 23, 2013
307–310.
Lassetter, J. H. (2006). The effectiveness of complementary
therapies on the pain experience of hospitalized
children. Journal of Holistic Nursing, 24, 196–208.
MacLaren, J. E., & Cohen, L. L. (2005). A comparison
of distraction strategies for venipuncture distress
in children. Journal of Pediatric Psychology, 30,
387–396.
Martz Huth, M., Broome, M. E., & Good, M. (2004).
Imagery reduces children’s post-operative pain. Pain,
110, 439–448.
Moran, C. C. (1998). Individual differences and debriefing
effectiveness. The Australasian Journal of Disaster
and Trauma Studies, Retrieved July 2, 2004, from
http://www.massey.ac.nz/trauma/issues/1998-1/
moran1.htm.
Powers, S. W. (1999). Empirically supported treatments in
pediatric psychology: procedure-related pain. Journal
of Pediatric Psychology, 24, 131–145.
Ramenofsky, M. L., Ramenofsky, M. B., Jurkovich, G. J.,
Threadgill, D., Dierking, B. H., & Powell, R. W.
(1988). The predictive validity of the Pediatric Trauma
Score. Journal of Trauma: Injury, Infection, and Critical
Care, 28, 1038–1042.
Recklitis, C. J., & Noam, G. G. (1999). Clinical and
developmental perspectives on adolescent coping.
Child Psychiatry and Human Development, 30, 87–101.
Schechter, N. L. (1989). The undertreatment of pain in
children: an overview. Pediatric Clinics of North
America, 36, 781–794.
Spirito, A., Stark, L. J., Gil, K. M., & Tyc, V. L. (1995).
Coping with everyday and disease-related stressors by
chronically ill children and adolescents. Journal of the
American Academy of Child and Adolescent Psychiatry,
34, 283–290.

Tanabe, P., Ferket, K., Thomas, R., Paice, J.,
& Marcantonio, R. (2002). The effect of standard
care, ibuprofen, and distraction on pain relief
and patient satisfaction in children with
musculoskeletal trauma. Journal of Emergency Nursing,
28, 118–125.
Tepas, J. J. III, Mollitt, D. L., Talbert, J. L., & Bryant, M.
(1987). The Pediatric Trauma Score as a predictor of
injury severity in the injured child. Journal of Pediatric
Surgery, 22, 14–18.
Tepas, J. J. III, Veldenz, H. C., Discala, C., & Pieper, P.
(1997). Pediatric risk indicator: An objective
measurement of childhood injury severity. The Journal
Mental Imagery for Pediatric Pain 31
of Trauma: Injury, Infection, and Critical Care, 43,
258–262.
Turner, H. N. (2005). Complex pain consultations in the
pediatric intensive care unit. AACN Clinical Issues, 16,
388–395.
Wong, D., & Baker, C. (1988). Pain in children:
comparison of assessment scales. Pediatric Nursing,
14, 9–17.
Youssef, N. N., Rosh, J. R., Loughran, M., Schuckalo, S. G.,
Cotter, A. N., Verga, B. G., & Mones, R. L. (2004).
Treatment of functional abdominal pain in childhood
with cognitive behavioral strategies. Journal of Pediatric
Gastroenterology & Nutrition, 39, 192–196.
Downloaded from http://jpepsy.oxfordjournals.org/ by guest on April 23, 2013