JOURNAL OF PEDIATRIC PSYCHOLOGY 24:4

Journal of Pediatric Psychology, Vol. 24, No. 4, 1999, pp. 305–328

Empirically Supported Treatments of DiseaseRelated Symptoms in Pediatric Psychology: Asthma, Diabetes, and Cancer Elizabeth L. McQuaid, PhD, and Jack H. Nassau, PhD Rhode Island Hospital/Brown University School of Medicine Objective: To review empirical studies of psychological treatments for (1) reducing physical symptoms in children and adolescents with asthma, (2) improving glycemic control in children and adolescents with diabetes, and (3) reducing chemotherapy side effects in children and adolescents with cancer. Methods: We identified peer-reviewed studies of effects of psychological treatments for asthma symptoms, diabetes symptoms, and side effects of cancer chemotherapy through computerized databases (i.e., PSYCHLIT and MEDLINE). Treatment approaches are evaluated with respect to meeting criteria for being “promising,” “probably efficacious,” or “well-established” based on the Chambless criteria (Chambless et al., 1996). Results: Two well-established treatments (EMG biofeedback for children with emotionally triggered asthma and imagery with suggestion for children undergoing chemotherapy) and two probably efficacious treatments (relaxation for children with emotionally triggered asthma and distraction with relaxation for children undergoing chemotherapy) were identified. Additional research is needed to evaluate the efficacy of treatments for diabetes-related symptoms. Conclusions: Future research would be enhanced by identifying characteristics of children who are likely to respond to psychological treatment as an adjunctive strategy for symptom management and by clearly elucidating mechanisms of effect of various interventions. Key words: intervention; childhood chronic illness; asthma; cancer; diabetes; review.

In current models of consultation, pediatric psychologists are most often consulted to intervene in the behavioral arena. Behavioral patterns that interfere with medical interventions, negative behaviors that have developed as a result of invasive treatments, and difficulties in emotional adaptation to disease are common targets for psychological intervention. Treatment for physical symptoms is typiAll correspondence should be sent to Elizabeth L. McQuaid, Department of Child and Family Psychiatry, Rhode Island Hospital, 593 Eddy St., Providence, Rhode Island 02903.

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cally within the purview of the medical treatment team. However, for a few disease- or treatmentrelated symptoms, medical and psychological interventions may share the same target outcome. The interface between psychological processes and physical symptoms is exceedingly complex. Interactions between emotional, behavioral, and perceptual processes and disease- or treatment-related symptoms occur on multiple levels. Chronic illnesses such as asthma and diabetes provide examples of conditions in which psychological factors

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are thought to play a role in initiating symptomatic periods (Isenberg, Lehrer, & Hochron, 1992; LaGreca & Spetter, 1992). This effect can occur through multiple channels, such as when individual and family factors affect symptom presentation and disease management, or when experiences such as stress have direct physiological consequences that affect disease course. Further, the experience of illness symptoms and their exacerbations can cause emotional distress. As a result, psychological factors such as stress may both initiate symptoms and mediate between disease process and symptom presentation. Within this context, psychological treatments can serve to decrease emotional precipitants to symptoms, decrease emotional distress as a result of symptoms, and provide patients with a sense of control over their physical condition. Medical treatments themselves can cause unpleasant side effects, from intense pain to nausea and vomiting. Physical discomfort from treatment side effects can cause considerable distress to children and adolescents who must undergo aversive treatments for their illness (Dolgin, Katz, Zeltzer, & Landsverk, 1989). Psychological interventions can also be utilized with this population to reduce treatment-related symptoms and to provide patients with strategies to reduce and manage their physical discomfort. What follows is an integrative review of psychological interventions geared toward alleviating physical symptoms in children and adolescents with chronic illness. Treatments for asthma and diabetes that reduce precipitants to symptoms and provide physical symptom relief will be reviewed. Since pain interventions and adherence programs are covered in other articles in this section, these treatments will not be addressed here. Although selfmanagement approaches are key psychological interventions for these populations, they will not be reviewed here, as they are often conceptualized to reduce symptoms indirectly, through improved symptom recognition and adherence. For excellent reviews of asthma and diabetes self-management approaches, the reader is referred to Bernard-Bonin, Stachenko, Bonin, Charette, and Rousseau (1995) and Goodall & Halford (1991), respectively. A separate section on psychological interventions for side effects of cancer chemotherapy is also included. Although these interventions are not thought to have a role in disease prevention, they can provide useful strategies for physical symptom management. Fi-

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nally, critical evaluations of treatment efficacy based on methodological rigor and short- and longterm effects of treatment will be presented. We will then offer recommendations for clinical application of findings and areas for further research.

Literature Search We identified peer-reviewed studies of effects of psychological treatments for asthma symptoms, diabetes symptoms, and side effects of cancer chemotherapy in two ways. First, MEDLINE and PSYCHLIT databases were searched by computer for studies published after 1970. Articles containing the words asthma, diabetes, or cancer combined with phrases relating to psychological treatments (e.g., treatment, intervention, therapy, relaxation, biofeedback) in the abstract or title were requested. Second, reference lists of obtained articles were searched for other relevant publications. Studies were included in the review if they met the following criteria: (1) inclusion of children or adolescents with the relevant target illness, and (2) administration of a psychological intervention in attempt to affect physical symptoms directly. Treatments for Asthma Symptoms Earlier in this century, asthma was theorized to be a “psychosomatic illness,” in which psychological factors were viewed as causal (Alexander, 1972). Psychoanalytic perspectives regarded unresolved dependency conflicts as central features in the development of pediatric asthma (e.g., French & Alexander, 1941). Subsequently, family systems variables were identified as critical in facilitating or interfering with adaptation to illness (Minuchin et al., 1975). Gains in understanding the pathophysiology of asthma over the past two decades have decreased emphasis on the investigation of psychological factors and, consequently, the role of psychological interventions. However, growing interest in holistic approaches that integrate psychology and medicine highlight a need to review the efficacy of these psychological interventions as adjunctive or interactive components of asthma treatment. The etiology of asthma is currently understood to be multifactorial. Central physiological features include predisposition to allergy, bronchial hyperreactivity, and chronic inflammation of the airways

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(Larsen, 1992). Emotions are seen as playing a direct role in triggering or potentiating exacerbations in some people (Isenberg et al., 1992). Psychological treatments for asthma symptoms have been described in three modalities: relaxation training for global changes in asthma status, biofeedback targeted to specific changes in pulmonary function, and family therapy to facilitate physical and emotional adjustment. Because these approaches are based on different underlying mechanisms of effect, we will review them separately. Appendix 1 presents summaries of treatment paradigms and results. Relaxation Training Early clinical observations of children and adults with asthma indicated that having patients “sit quietly and relax” during an asthma exacerbation was often useful in decreasing symptoms (Alexander, Miklich, & Hershkoff, 1972). A number of research efforts have investigated the efficacy of relaxation training for adults with asthma, with equivocal results (see Lehrer, Sargunaraj, & Hochron, 1992, for a review). These interventions are based on the premise that if asthma exacerbations are associated with increased autonomic arousal and increased emotional distress, relaxation to decrease arousal should provide some relief for asthma symptoms. A series of early studies (Alexander, 1972; Alexander et al., 1972) investigated the efficacy of progressive muscle relaxation (PMR; Jacobson, 1938) in improving pulmonary function measures, primarily peak flow (PEFR) in children with severe asthma. Alexander and colleagues first used a within-subjects design (Alexander, 1972) and subsequently a between-subjects design (Alexander et al., 1972) to assess the effects of this method among children hospitalized in a residential treatment facility for asthma. Both studies demonstrated modest increases in PEFR across experimental sessions either in comparison to baseline (Alexander, 1972) or in comparison to a control group intervention (Alexander et al., 1972). Despite the strengths of these studies, which include clear specification of intervention strategy, and an appropriate control group comparison (Alexander et al., 1972), they are limited by their lack of long-term follow-up. Although this approach is intuitively appealing, careful consideration of the physiological mechanisms that link emotions to airway changes suggest the relationship between relaxation and airway resistance may be more complex than initially as-

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sumed. As noted earlier, for a proportion of individuals with asthma, emotions can trigger asthma exacerbations (see Isenberg et al., 1992, for a review). However, in general, activation of the autonomic nervous system under significant stress results in sympathetic arousal, which leads to bronchodilation, to enable the organism to mobilize for “fight or flight” (Nadel & Barnes, 1984). Review of many studies in relaxation training suggests that the extent to which emotions serve as a trigger for asthma episodes may moderate the efficacy of the intervention. This follows logically from the assertion that asthma may, in part, result from a functional imbalance between the parasympathetic and sympathetic nervous system (ErskineMilliss & Schonell, 1981). Hence, targeting individuals who have the atypical response of increased bronchoconstriction under stress may be the most useful approach. In Alexander’s (1972) study, children who, on individual interview, reported emotional triggers to their asthma had improvement in peak flow in response to relaxation. Miklich et al. (1977) specifically selected children with a history of “emotional precipitants” to their asthma for intervention as indicated by one clear documented instance of emotions triggering an episode of asthma. Their treatment involved a well-specified protocol combining relaxation training with systematic desensitization to anxiety-provoking triggers. Results indicated some changes in pulmonary function for the treatment group compared to the control group. Small but significant changes were maintained at 5-month follow-up. A series of more recent studies lends further support for the efficacy of relaxation training for children with emotional triggers to their asthma. In a series of studies with overlapping samples, Vazquez and Buceta (1993a, 1993b, 1993c) investigated the efficacy of relaxation training, separately and in combination with self-management for children with asthma. They found little evidence that relaxation training alone produced global changes in pulmonary function. However, in one published report they assessed whether a history of emotionally triggered asthma episodes (determined by a method similar to that of Miklich et al., 1977) affected the child’s response to relaxation training and selfmanagement. Results indicated that, compared to self-management alone, the combination of relaxation training and self-management decreased asthma attack duration the most in children with a

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history of emotional triggers. Furthermore, pulmonary function variables showed the greatest changes over time in these children compared to children without a history of emotional triggers (Vazquez & Buceta, 1993a). The research regarding relaxation training as an intervention for asthma symptoms suffers from a number of methodological shortcomings. Although most studies reviewed (five of six) used betweengroups designs, only three (Alexander et al., 1972; Vazquez & Buceta, 1993b, 1993c) used appropriate attention control groups. Only one study (Miklich et al., 1977) assessed whether changes in pulmonary function status were maintained posttreatment. Despite these concerns, the consistent changes found in the literature suggest that relaxation training is a probably efficacious intervention for children with emotionally triggered asthma. The pulmonary function changes demonstrated in the studies cited are statistically significant for the entire treatment group (e.g., Alexander, 1972; Alexander et al., 1972) or for those with emotional triggers (Miklich et al., 1977; Vazquez & Buceta, 1993a). However, it should be noted that these changes may fall short of clinical significance, as they typically represent changes of less than 10% of initial values (King, 1980). Biofeedback Over the past two decades, selected research has examined biofeedback as an intervention for asthma symptoms. An essential assumption of biofeedback training is that individuals can learn to influence their physical symptoms if provided with continuous feedback on a relevant physiological parameter. In asthma, specification of the appropriate channel for feedback has been a topic of debate. Spirometry to assess pulmonary function typically involves an effortful “blow” to assess maximum lung function capacity, a technique that does not naturally lend it to continuous feedback. Biofeedback interventions have been used to either (1) provide feedback regarding general muscle relaxation, (2) increase airflow through EMG trigeminal biofeedback, or (3) decrease respiratory resistance directly through tonal and/or visual feedback. These three approaches represent fundamentally different mechanisms of effect to decrease asthma symptoms. For example, providing biofeedback regarding the degree of muscle relaxation builds on the same principles as relaxation approaches outlined before, namely, that

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increasing relaxation will decrease bronchoconstriction. The proposed mechanisms underlying EMG trigeminal feedback and feedback linked directly to airway resistance will be described in the text that follows. One of the first studies to assess biofeedback-assisted relaxation training was conducted with children hospitalized with moderate to severe asthma (Davis, Saunders, Creer, & Chai, 1973). In this study, children were assigned to receive either biofeedback-assisted PMR, PMR without biofeedback, or a control condition (sitting quietly and reading). The biofeedback-assisted PMR group demonstrated the greatest increases in PEFR, followed by the PMRonly group. However, these changes fell short of clinical significance and were seen largely as intriguing findings to indicate further research (Davis et al., 1973). Scherr, Crawford, Sergent, and Scherr (1975) subsequently investigated the efficacy of biofeedback-assisted relaxation training in an asthma camp setting. A treatment group receiving this intervention was compared to a control group that received no intervention aside from regular camp participation. The experimental group evidenced fewer infirmary visits and fewer asthma exacerbations over the course of camp. However, because the control group did not receive any form of alternative treatment, it is difficult to determine whether increased attention due to study participation may have served as an intervention itself for the experimental group. In these first few studies, biofeedback was used primarily to facilitate relaxation training. However, researchers began to hypothesize that there might be a specific mechanism to EMG frontalis biofeedback that had specific effects on pulmonary function. It was hypothesized that facial muscle tension and airflow resistance might be related by a reflexive mechanism with trigeminal and vagal components (Glaus & Kotses, 1983; Kotses & Glaus, 1981). In explaining this hypothesis, Glaus and Kotses draw a parallel to the neural reflex that mediates the relationship between limb muscle tension (e.g., through running) and subsequent lung ventilation (e.g., rapid respiratory rate). In the trigeminal/vagal model, stress is hypothesized to trigger facial tension, which initiates the reflex loop. The nerves that control the skeletal muscles of the throat and face synapse on the brainstem and result in vagal efferent activity. The vagus has direct effects on bronchomotor tone, which then result in increases in


airway resistance. Hence, relaxing the trigeminal muscles could result in the opposite effect, or decreases in airway resistance. In a small series of carefully designed experiments, Kotses and colleagues (Kotses, Glaus, Bricel, Edwards, & Crawford, 1978; Kotses, Glaus, Crawford, Edwards, & Scherr, 1976; Kotses et al., 1991) investigated the efficacy of EMG biofeedback to reduce facial muscle tension and affect pulmonary function in children with asthma. In their first published study, Kotses et al. (1976) evaluated the efficacy of EMG frontalis biofeedback in increasing PEFR values in a between-groups design with a contingent feedback group, a noncontingent feedback group, and a no-treatment control group. The greatest reduction in frontalis muscle tension and the greatest increases in PEFR were found in the contingent feedback group. Subsequently, they used a yoked control-group design to compare this intervention to EMG brachioradialis biofeedback (Kotses et al., 1978). In this design, control groups for each type of biofeedback learned the procedure, but received noncontingent feedback regarding their state of muscle relaxation. Results revealed the EMG frontalis treatment group (who received performance-contingent feedback) achieved the greatest changes in PEFR. More recently, Kotses et al. (1991) evaluated the short- and long-term effects of this technique on measures of pulmonary function and asthma severity in children. Children in the treatment group received EMG frontalis biofeedback training to reduce muscle tension and were instructed to practice techniques at home. Children in the control group received EMG frontalis biofeedback training for facial muscle tension stability and received similar instructions for home practice. The treatment group demonstrated higher pulmonary function scores during the follow-up period. The strengths of treatment studies evaluating biofeedback for EMG frontalis activity to improve asthma symptoms include the careful selection and matching of subjects, the clear specification of treatment approach, the appropriate control group conditions, and the inclusion of long-term follow-up in the most recent study (Kotses et al., 1991). The evaluation of relevant indices of clinical status, such as measures of clinical symptoms and asthma severity in the groups’ most recent (1991) study, provide further evidence for the merits of this approach. However, a critical premise of this approach is that

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the main symptom target should be increased bronchodilation. Recent work regarding the pathophysiology of asthma suggests that chronic inflammation also plays a critical role in the expression of asthma symptoms (Larsen, 1992; National Asthma Education and Prevention Program, 1997). Future research in this area could be strengthened by attempts to affect both bronchomotor tone and inflammation, or to control for the influence of inflammation, such as by including children at different levels of antiinflammatory medications. Although biofeedback to decrease respiratory resistance directly has been evaluated in adults with some modest results (e.g., Janson-Bjerklie & Clark, 1982; Vachon & Rich, 1976), only one study (Feldman, 1976) investigated this technique with children. In a small pilot study (n 5 4), Feldman utilized methods of forced oscillation to provide feedback to decrease respiratory resistance. In such a procedure, subjects receive tonal feedback through headphones that increases in pitch as a function of increases in respiratory resistance. Despite the limited statistical power of this study, Feldman’s findings of lowered airway resistance for all subjects suggest this technique may bear further investigation. Lack of further research utilizing this technique is likely due to the sophisticated equipment necessary for such a procedure and the limited data regarding the relationship of measures of respiratory resistance to standard measures of spirometry. Overall, the findings reviewed here indicate that biofeedback to reduce EMG frontalis muscle tension is a well-established treatment for children with asthma, and that biofeedback to decrease respiratory resistance merits further controlled research. The modest findings documented by various researchers using these paradigms may be due to individual differences in response to treatment. Given the heterogeneity of the asthmatic population, future research should investigate variables that might moderate treatment outcome. Research regarding relaxation training suggests that children with emotionally triggered asthma episodes may be likely candidates for intervention. Asthma severity may also play a significant role. Finally, if a child’s asthma is easily controlled with inhaled bronchodilators, they may be more likely to respond to an intervention targeted toward decreased respiratory resistance than a child whose asthma requires antiinflammatory medications. Future research is needed to determine whether efforts to affect in-

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flammation through biofeedback and/or imagery might also provide some benefit. Family Therapy Family therapy approaches to asthma have their roots in clinical literature describing maladaptive patterns of adaptation to childhood chronic illness. These models delineated how parental focus on illness might divert attention from other key family issues (e.g., Minuchin et al., 1975). More recently, empirical work has demonstrated that certain types of maladaptive family interactions, such as parental criticism of the child, may affect the course of asthma (Hermanns, Florin, Dietrich, Rieger, & Hahlweg, 1989; Schobinger, Florin, Zimmer, Lindemann, & Winkler, 1992; Wamboldt, Wamboldt, Gavin, Sarlin, & White, 1993). In sum, clinical impressions and empirical data indicate that family treatment might be useful in improving disease symptoms. Despite the intuitive appeal of family therapy approaches to asthma treatment, only two treatment outcome studies (Gustaffson, Kjellman, & Cederblad, 1985; Lask & Matthew, 1979) have investigated the efficacy of this approach in demonstrating changes in physical symptoms. Each of these studies targeted their treatments toward children with more severe asthma, citing literature that psychosocial and family factors are essential elements in the management of severe forms of the illness. Both studies used a between-groups design, with small control groups of children with severe asthma receiving regular clinic care. Unfortunately, poor specification of treatment protocol in each study hampers evaluation of the overall approach. Target variables for family intervention are not well delineated. For example, Gustaffson and colleagues (1985) describe a number of global target variables, such as “exploring the role of illness in the family.” Although they provide a reference for a description of their approach, there appears to be no programmatic sequence of treatment or time limit in which to achieve treatment goals. In contrast, Lask and Matthew (1979) provide a reference for their treatment approach (Lask & Kirk, 1979) and do appear to have a standard 6session format. However, it should be noted that neither study gives an adequate description of clinician qualifications, attempts to monitor treatment integrity, or evaluates psychosocial outcome variables. Despite these methodological shortcomings, re-

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sults indicate some modest changes in child pulmonary function for each study. Lask and Matthew (1979) found significant increases in thoracic gas volume and decreases in day-wheeze scores at the end of treatment. The treatment implemented by Gustaffson and colleagues (1985) yielded significant differences in the overall pediatric assessment, including reduced need for medication and reduced days of functional impairment. Differences in overall PEFR, measured at the time of clinic visits, did not change over the course of treatment. In sum, although some of these results are promising, clearly better controlled research is needed to determine the efficacy of family therapy approaches in reducing symptoms of asthma. Treatments to Improve Metabolic Control in Children and Adolescents with InsulinDependent Diabetes Mellitus (IDDM) The relationship between psychosocial stress and metabolic control in children and adolescents with IDDM is complex. The extent to which stress affects metabolic control directly versus its being mediated through adherence is not entirely understood (Johnson, 1988). Stress-related hormones (i.e., catecholamines) are known to result in hyperglycemia by suppressing the release and metabolic effects of insulin. Because they rely on exogenous replacement of insulin, it has been hypothesized that IDDM patients may be especially susceptible to stress-related hyperglycemia (Gilbert, Johnson, Silverstein, & Malone, 1989). However, research examining the relationship between stress and metabolic control has not clearly supported this hypothesis. First, although patients perceive a relationship between stress and metabolic control, the perceived strength of this relationship differs among patients as well as by stressor (Cox, Taylor, Nowachek, Holley-Wilcox, & Guthrow, 1984). Second, whereas self-reports of stress are often associated with poorer metabolic control (Cox et al., 1984; Hanson, Henggeler, & Burghen, 1987; Hanson & Pichert, 1986; see Delamater, Kurtz, Bubb, White, & Santiago, 1987, for an exception), studies in which acute stress has been experimentally manipulated have not shown a consistent relationship between stress and metabolic control among adults (Halford, Cuddihy, & Mortimer, 1990; Kemmer et al., 1986) or children (Gilbert et al., 1989). Instead, results indicate that the direct effects of stress on metabolic control are not uniform across patients and that metabolic


control may be sensitive to stress among only a particular subgroup of patients with IDDM (GonderFrederick, Carter, Cox, & Clarke, 1990). Nonetheless, because metabolic control frequently deteriorates in adolescence, psychological interventions aimed at reducing psychosocial stress, namely psychoanalysis, social skills training, and stress management training, have been used to improve metabolic control in adolescents with IDDM (see Appendix 2). The underlying premise of these interventions was that a decrease in psychosocial stress would lead directly to improved metabolic control. Metabolic control was operationalized as urine or blood glucose levels. Glycosylated hemoglobin A1c (HbA1c) was the most frequently used measure of metabolic control, although urine glucose measurements were sometimes employed. HbA1c reflects metabolic control during the 2–3 months preceding the test. The major difficulty in evaluating the overall efficacy of any of these interventions is the very small number of studies that have implemented and assessed them. Psychoanalysis Moran and colleagues (Moran & Fonagy, 1987; Moran, Fonagy, Kurtz, Bolton, & Brook, 1991) reported the results of two studies evaluating the efficacy of psychoanalysis in improving metabolic control in adolescents with IDDM (see Appendix 2). The rationale for using psychoanalysis to treat metabolic dyscontrol was based on the premise that patients adapt to unconscious conflict (i.e., stress) by mismanaging their disease. Insight into unconscious conflict and its impact on management was hypothesized to alleviate the conflict and, thus, promote better management and improved metabolic control. In their initial study (Moran & Fonagy, 1987), a nonexperimental single-case design that used a retrospective chart review of 3.5 years of psychoanalysis, expression and interpretation of conflictual themes during treatment were correlated with improved metabolic control 1–4 weeks later. However, the strength of this finding is severely limited by the large number of correlations computed (and concurrent lack of statistical correction) and relatively low percentage of variance accounted for by the association. In their follow-up study (Moran et al., 1991), concerted attempts were made to improve methodological rigor. This study investigated the impact of psychoanalysis 3–5 times weekly (for an average of

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15 weeks) versus education on metabolic control in a sample of adolescents hospitalized due to their IDDM. Results indicated that subjects who received psychoanalysis were in better metabolic control at hospital discharge than those who received the educational intervention. In addition, patients receiving psychoanalysis had lower HbA1c values 3 and 12 months posttreatment than at baseline. Although promising, these findings are limited by the fact that patients in the educational condition received far less intensive treatment over a shorter period of time than those in the psychoanalysis condition. Furthermore, although the authors refer to published principles that guide their treatment, it is unclear whether it could be standardized and used reliably by other practitioners. Social Skills Training Social skills training aimed at reducing psychosocial stress by improving interpersonal functioning was evaluated in two studies that produced contradictory findings (see Appendix 2). In a small study, Gross, Heimann, Shapiro, and Schultz (1983) reported that their intervention did not affect HbA1c despite improvements in social skills. In contrast, in a study of adolescents attending an IDDM summer school program (Kaplan, Chadwick, & Schimmel, 1985), subjects receiving social skills training had lower HbA1c values 4 months posttreatment than those receiving educational information. However, contrary to hypotheses, ratings of social support and problem-solving ability were associated with poorer metabolic control (i.e., higher HbA1c values). Additional well-controlled studies that specifically target children whose diabetes responds negatively to stress and who have poor diabetes-related social skills are needed to determine the efficacy of this treatment. Stress Management Another small number of studies evaluated the impact of stress management training on improving metabolic control in IDDM (see Appendix 2). Rose, Firestone, Heick, and Faught (1983) used a multiple baseline design, with an attention-control phase, in a study of five adolescents with “poorly controlled” IDDM. Although the intervention did not affect reports of anxiety, diabetic control (as measured by urine glucose percentage) was improved during the treatment phase relative to baseline and attentioncontrol phases. No long-term follow-up data were reported. Boardway, Delamater, Tomakowsky, and

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Gutai (1993) randomly assigned 20 adolescents with IDDM to either stress management training or standard care. Although subjects receiving stress management training reported less stress associated with diabetes than controls, the groups did not differ in HbA1c at the conclusion of treatment or at follow-up assessments 6 and 12 months later. With only two published reports, it is again difficult to draw conclusions about the efficacy of stress management training in IDDM. As in the case of asthma, it may be that such intervention is useful, but only for patients whose illness is adversely affected by stress. As Boardway et al. (1993) note, future research would benefit from targeting children whose disease control responds negatively to stress and including relaxation training as an aspect of treatment.

self-report measures of distress (e.g., anxiety) are used to measure stress, these should be supplemented with physiological measures because in some people (i.e., those who use repressive-defensive coping), self-reports of distress and physiological indices of stress may be discrepant (Weinberger, 1979). The manner in which people cope with stress, rather than the experience of stress per se, may be a key variable in the relationship between stress and metabolic control (Delamater et al., 1987). Finally, because stress may influence metabolic control indirectly through affecting patterns of adherence, research should also assess how stressreducing intervention changes patterns of adherence and whether changes in metabolic control can be attributed directly to reductions in stress or to changes in adherence (Hanson et al., 1987).

Summary of Treatments to Improve Metabolic Control among IDDM Patients As indicated, because of the small number of studies that have evaluated the effectiveness of psychological treatments to directly improve metabolic control, efficacy of these treatments is difficult to determine. In addition, studies of particular treatments have often produced contradictory results (Gross et al., 1983,versus Kaplan et al., 1985; Rose et al., 1983, versus Boardway et al., 1993) and/or results that did not support the hypothesis that improved metabolic control resulted from reduction of stress as operationalized in the study (e.g., Kaplan et al., 1985; Rose et al., 1983). Finally, when intervention was found to reduce stress, this reduction was often not associated with improved metabolic control (Gross et al., 1983; Boardway et al., 1993). These inconsistent results underscore the complex relationship between stress and metabolic control in patients with IDDM. The following suggestions are made to advance research in this area. First, research would benefit from identifying patients whose metabolic control is adversely affected by stress. For example, only patients whose metabolic control fluctuates during a stressful laboratory task could be included. For clinical reasons, the reviewed research often included patients who were in poor metabolic control; however, the potential antecedents (e.g., stress or poor adherence) to such poor control were not assessed. Second, inclusion of treatments (e.g., relaxation training) that are known to affect physiological indices of stress would provide a more direct test of the relationship between stress and metabolic control. Third, when

Treatments to Alleviate Cancer Chemotherapy Side Effects Aggressive chemotherapy regimens to treat a variety of pediatric and adult malignancies are associated with untoward side effects, including anticipatory and postchemotherapy nausea and vomiting. Redd and Andrykowski (1982) estimate that roughly 25% of adult patients develop anticipatory nausea and vomiting over the course of treatment. In pediatric samples, the occurrence of both anticipatory and postchemotherapy symptoms may be more variable than in adults, with greater percentages of adolescents affected than children. This pattern may result because chemotherapy protocols for adolescents use agents with more potential to cause nausea and vomiting. Dolgin et al. (1989) reported that 36% of newly diagnosed adolescents developed anticipatory nausea and vomiting while more than 75% experienced postchemotherapy nausea and vomiting. Rates of anticipatory and postchemotherapy symptoms were much lower in children (6% and 40%, respectively). Anticipatory symptoms are hypothesized to develop by means of classical conditioning in which previously neutral stimuli (e.g., the treatment room) elicit nausea and vomiting through repeated associations with chemotherapy (Redd & Andrykowski, 1982). Since antiemetic medications are frequently not entirely effective in controlling these symptoms, behavioral interventions have been implemented in both adult and pediatric populations. Redd and Andrykowski provide a review of the effectiveness of varying self-regulatory techniques


including guided imagery, relaxation, and biofeedback with adults. In pediatric samples, imagery (usually with some form of hypnotic suggestion), active cognitive distraction with relaxation training (sometimes referred to as “standard care”), and video games have been employed to reduce the frequency, duration, or severity of either anticipatory or postchemotherapy nausea and vomiting (see Appendix 3). All but one study that evaluated the effectiveness of cognitive distraction with relaxation compared it to an imagery-based intervention. Therefore, these two interventions will be discussed together. The major methodological challenges facing these studies are (1) the inclusion of patients with varying diagnoses and thus varying chemotherapy protocols with differential potential to produce nausea and vomiting, and (2) difficulty obtaining long-term follow-up data due to changing treatment protocols. Methodological rigor was enhanced by including only patients who were experiencing adverse chemotherapy side effects (i.e., nausea and vomiting), quantifying antiemetic use, and ensuring that chemotherapy regimens remained consistent throughout the study. Imagery and Active Cognitive Distraction with Relaxation Theoretically, there are several potential mechanisms through which nausea and vomiting among cancer patients undergoing chemotherapy might be alleviated by imagery-based or cognitive distraction/relaxation interventions. First, patients may be distracted from chemotherapy sensations by focusing their attention on imagery that is more pleasurable or on activities. Second, either arousal or relaxation associated with particular images or activities may affect symptom perception or physiological processes such as gut motility and gastric acid production. Third, children’s perceptions of control and, thus, their ability to cope with chemotherapy side effects may be enhanced by the realization that they can learn to engage in some competing activity (imagery, cognitive distraction, relaxation) during chemotherapy. Perceptions of control may also be enhanced by specific suggestions made during imagery-based interventions. It should be noted that these mechanisms are not mutually exclusive and may, in fact, synergistically produce treatment effects. The typical imagery-based intervention consisted of (1) helping the patient develop vivid imagery and (2) providing suggestions, both with respect

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to the antiemetic nature of the imagery and, more generally, about being comfortable/relaxed during chemotherapy administration. In addition to offering supportive assistance, the typical intervention using active cognitive distraction combined with relaxation included instructing patients to focus their attention on objects in the treatment room or on an activity (e.g., playing games) and teaching some form of relaxation (e.g., deep breathing or relaxing of muscle groups). Seven studies of imagery-based or active cognitive distraction with relaxation interventions reported that the intervention had a positive impact on nausea and vomiting associated with cancer chemotherapy (see Appendix 3). In one uncontrolled study of active cognitive distraction and relaxation with a multiple baseline design (LeBaron & Zeltzer, 1984), children’s postchemotherapy ratings of nausea and vomiting were reduced during 2–3 treatment-phase courses of chemotherapy. Unfortunately, conclusions about whether reduction in symptoms reflected reduced frequency, severity, or duration were not possible. In two single-case studies of imagery-based intervention with A-B designs (Ellenberg, Kellerman, Dash, Higgins, & Zeltzer, 1980; Kaufman, Tarnowski, & Olson, 1989), frequency of anticipatory, concurrent, and postchemotherapy nausea and vomiting was reduced during the treatment phase and, in Kaufman et al. (1989), during follow-up assessments. Kaufman et al. (1989) used a multicomponent intervention that included relaxation training, child practice of techniques at home, and parental involvement in addition to imagery and suggestion; thus, it is unclear whether the imagery component or one of the other components (or some combination of components) was responsible for the reduction in symptoms. In an additional study of imagery-based intervention (Zeltzer, Kellerman, Ellenberg, & Dash, 1983), frequency and perceived intensity of vomiting were reduced during a postintervention chemotherapy course compared to during a preintervention chemotherapy course. Controlled studies, in which the effectiveness of imagery-based interventions with suggestion was compared to that of active cognitive distraction combined with relaxation, provide further support for the efficacy of these interventions in alleviating nausea and vomiting associated with chemotherapy. Cotanch, Hockenberry, and Herman (1985) reported that patients who participated in a onesession imagery-based intervention experienced de-

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creases in intensity and duration of nausea and in frequency, amount, severity, and duration of vomiting compared to patients who received cognitive distraction and relaxation. In a similar comparison of interventions (imagery with suggestion vs. active cognitive distraction with relaxation), Zeltzer, LeBaron, and Zeltzer (1984) found that nausea and vomiting severity in both groups of patients were reduced from baseline to treatment. Finally, in a particularly well-controlled study, Zeltzer, Dolgin, LeBaron, & LeBaron (1991) found that children receiving either an imagery-based intervention or active cognitive distraction with relaxation had shorter duration of nausea compared to an attentioncontrol group, but that only patients receiving the imagery intervention had shorter duration of vomiting. These findings support the conclusion that imagery-based intervention, during which patients develop vivid fantasy imagery and receive suggestions aimed at increasing comfort during chemotherapy, is a well-established treatment for reducing anticipatory and postchemotherapy nausea and vomiting in pediatric cancer patients. However, the specific mechanism by which these symptoms are reduced by the intervention remains unclear. Furthermore, in the reviewed studies, imagery interventions do not appear to be more effective than active cognitive distraction with relaxation (a probably efficacious treatment), except possibly with respect to reducing duration of vomiting. Video Games Three studies evaluated the effectiveness of access to video games prior to or during chemotherapy in reducing symptoms among pediatric cancer patients (see Appendix 3). Video games were conceptualized as an intervention that would reduce symptoms by distracting patients from chemotherapy sensations. Furthermore, it was assumed that video games would provide a cleaner test of the impact of distraction because distraction would not be confounded with relaxation. Kolko and RickardFigueroa (1985) conducted a multiple baseline, ABAB design study with three adolescents. Clinic resources (e.g., TV) were available during baseline chemotherapy sessions whereas video games (in addition to clinic resources) were available during treatment sessions. Both anticipatory and postchemotherapy symptoms were reduced to varying degrees in the three adolescents during the treatment versus baseline chemotherapy courses. However,

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data were not analyzed to specifically determine the impact of the intervention on nausea and vomiting independent of other symptoms (e.g., had cold hands, shakiness). Redd et al. (1987) reported the results of two studies (listed separately in Appendix 3) utilizing video games. These studies differed from that of Kolko and Rickard-Figueroa (1985) in that baseline and intervention data were collected just before the same chemotherapy session rather than over different chemotherapy sessions. The first experiment compared baseline to treatment ratings of nausea severity in patients who received 10 minutes of video game access and in those who had access only to clinic resources (e.g., TV). Ratings of nausea severity decreased from baseline to treatment in the patients who had access to video games, but not in those who only had access to clinic resources. The second experiment utilized an ABAB design in which patients alternatively did not have access to video games for 10 minutes and then had access to video games for 10 minutes. Nausea severity was rated at the end of each 10-minute period. Ratings of nausea severity decreased from each baseline to video game period and increased from video game to the second baseline period. The major methodological shortcoming of studies evaluating the efficacy of video games in reducing chemotherapy side effects is the lack of control group comparisons in all but one study (the second experiment reported by Redd et al., 1987). However, the use of multiple baseline assessments strengthens the findings. Based on these early findings, video game distraction may be an especially promising intervention. The obvious appeal of video games to pediatric patients and their ease of administration adds to their attractiveness as a potentially cost-effective and nonlabor-intensive intervention. However, although video games were hypothesized to be effective because of their ability to distract patients from chemotherapy sensations, these studies do not rule out the possibility that arousal or even relaxation were the principles by which symptoms were reduced. Summary of Treatments to Alleviate Chemotherapy Side Effects The reviewed studies of interventions to reduce anticipatory and postchemotherapy nausea and vomiting among pediatric cancer patients indicate that imagery with suggestions is a well-established treatment, active cognitive distraction with relaxation


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Table I. Evaluation of Treatment Efficacy by Disease and Intervention Disease

Intervention

Treatment Efficacy

Asthma Relaxation

Probably efficacious for those with emotional triggers

Biofeedback

Frontalis EMG biofeedback well-established

Family Therapy

Promising

Psychoanalysis

Further research needed to determine efficacy

Social Skills Training


Stress Management


Imagery with Suggestion

Well-established

Diabetes

Cancer-chemotherapy side effects Distraction with Relaxation

Probably efficacious

Video Games

Promising

is a probably efficacious treatment, and access to video games is a promising intervention. However, at least two important areas remain to be clarified. First, as discussed, there are many possible mechanisms (e.g., distraction, relaxation, or arousal altering central symptom perception and/or gut motility through autonomic nervous system changes, for example) by which chemotherapy side effects might be reduced by these interventions. The current research does not allow conclusions about what mechanism produced the results because these mechanisms were not measured directly. Future research might include measures of physiological indices such as skin conductance, peripheral temperature, muscle tension, and heart rate to assess whether the patient is aroused or relaxed. Second, it is unclear whether a particular treatment or mechanism affects specific symptoms or all symptoms. The literature seems to indicate that imagery, cognitive distraction with relaxation, and video games may be equally effective in reducing nausea, but that imagery may be more effective than the other treatments in reducing vomiting, particularly its duration (Zeltzer et al., 1991). By measuring the specific mechanisms of these processes, future research could help clarify which mechanisms are helpful in reducing which symptoms and then target interventions for children experiencing particular symptoms.

Conclusions The reviewed research highlights some wellestablished psychological treatments for directly alleviating physical symptoms in children with

asthma and in children experiencing chemotherapy side effects (see Table I). The most well-established treatments appear to be EMG biofeedback to reduce frontalis muscle tension for children with asthma (resulting in increased PEFR) and imagery with suggestion to reduce cancer treatment side effects. These treatments are supported by well-controlled research that, in some cases, includes long-term follow-up. A few interventions reviewed are probably efficacious, despite some inconsistent effects. These include relaxation training for children with emotionally triggered asthma, and distraction with relaxation for cancer-chemotherapy side effects. The treatments considered promising include family therapy for asthma and video games for cancer chemotherapy side effects. Additional research evaluating psychological treatments for improving metabolic control among children with adolescents with IDDM is needed before any determination of efficacy can be made. In general, future research needs to provide a clearer assessment of the specific mechanism of effect of each intervention. This could be achieved by including additional measures of physiological and psychological variables that change in conjunction with treatment effects. For example, measurement of physiological indices of relaxation would help clarify the potential mechanism of effect in studies of treatments designed to reduce side effects of cancer chemotherapy. Including treatment groups that receive varying components of the intervention (such as incorporating relaxation into a self-management protocol as in Vasquez & Buceta, 1993a) could help identify the most “active ingredient” of complex interventions.

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Review of this body of diverse research highlights that clearer specification of appropriate target populations might improve overall ratings of treatment efficacy. Identifying key moderators of treatment efficacy, such as physiological reactivity to stress, could result in less heterogeneous results. It seems clear that children with emotionally triggered asthma are more likely to benefit most from current psychological approaches to improve pulmonary function. Among children with diabetes, treatments to improve glycemic control by reducing psychosocial stress (e.g., social skills training and stress management training) may be most effective for children whose glycemic control is adversely affected by stress. Matching treatment approach to child temperament in psychological interventions for chemotherapy side effects (e.g., using video games with children who are uncomfortable with imagery-based intervention) could result in more effective treatments. Striving to identify these moderators of treatment efficacy will help us delineate the most effective psychological treatments for reducing physical symptoms associated with childhood chronic illness and its treatment. Finally, it should be noted that most, if not all, of these treatments take place in conjunction with complex medical regimens with multiple physiological effects. Much of prior research has viewed these psychological interventions in isolation from medical treatments. Clinical utility of these interventions would be enhanced by studying them in conjunction with medical management. For example, demonstrating that improvements in PEFR result in reduced need for medication without increased morbidity would facilitate disease management. Investigating the synergy between psychological and medical treatments, and the mechanisms for feedback between these approaches, is a clear priority for future research.

Appendix 1 Description of reviewed studies and treatment outcomes for asthma (by intervention) Relaxation training Alexander, A. B. (1972). Systematic relaxation and flow rates in asthmatic children: Relationship to emotional precipitants and anxiety. Journal of Psychosomatic Research, 16, 405–410.

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Sample. N5 25 (44% female, 10–15 years old). Diagnostic criteria. Inclusion: 10–15-year-old inpatients in residential program for children with asthma. Diagnosis: severe asthma. Experimental design. Within subjects; AB design. Baseline. Five sessions. Assessment measures. Physiological variables: Best of 3 Peak Flow Rate (PEFR) measurements post treatment. Other variables: Spielberger State-Trait Anxiety Inventory, emotional trigger interview. Treatment protocol. Treatment: Jacobsonian progressive muscle relaxation (PMR), referenced, 30 min/ day for 5 days. Results. Physiological variables: greater increases in PEFR across treatment vs. control sessions. Subjects reporting emotional triggers had greater changes in PEFR. Follow-up (Results). None. Alexander, A. B., Miklich, D. R., & Hershkoff, H. (1972). The immediate effects of systematic relaxation training on peak expiratory flow rates in asthmatic children. Psychosomatic Medicine, 34, 388– 394. Sample. N 5 36 (50% female, 10–15 years old, mean age 5 11.9 years). Treatment group (n 5 20); control group (n 5 16). Diagnostic criteria. Inclusion: 10–15 year old inpatients in residential program for children with asthma. Diagnosis: Severe asthma Experimental design. Between subjects, AB design. Baseline. None. Assessment measures. Physiological variables: Best of 3 PEFR measurements post treatment. Other variables: subjective ratings of relaxation. Treatment protocol. Treatment: Jacobsonian PMR (described, referenced), six 20-minute sessions. Control: sitting quietly, six 20-minute sessions. Results. Physiological variables: increase in PEFR (pre-post) over last 3 sessions for treatment group. Follow-up (Results). None. Miklich, D. R., Renne, C. M., Creer, T. L., Alexander, A. B., Chai, H., Davis, M. H., Hoffman, A., & Danker-Brown, P. (1977).


The clinical utility of behavior therapy as an adjunctive treatment for asthma. Journal of Allergy & Clinical Immunology, 60, 285–294. Sample. N 5 26 (mean age 5 11.8 years). Treatment group (n 5 19); control group (n 5 7). Diagnostic criteria. Inclusion: h/o “emotional precipitants” to asthma. Diagnosis: moderate to severe asthma, diagnosed by physician. Experimental design. Between groups, AB. Assignment: “Quasi-random”-children assigned to control group when therapist unavailable. Baseline. One pre-treatment assessment. Assessment measures. Physiological variables: forced expiratory volume in the first second (FEV1) 2 times daily; medication, and symptom frequency. Treatment protocol. Systematic Desensitization by Reciprocal Inhibition (SDRI), referenced, individualized length treatment: SDRI-relaxation paired with anxiety hierarchy. Control: relaxation only. Results. Physiological variables: no differences in asthma severity post-treatment; difference in change scores for A.M. and P.M. FEV1 for treatment group; evening wheezing change scores better in controls. Follow-up (Results). Treatment group had better FEV1 change scores at follow-up. Vazquez, I., & Buceta, J. (1993a). Effectiveness of self-management programmes and relaxation training in the treatment of bronchial asthma: Relationships with trait anxiety and emotional attack triggers. Journal of Psychosomatic Research, 37, 71–81. Sample. N 5 18 (28% female, 8–13 years old, mean age 5 10.7). Treatment group (n 5 9); control group (n 5 9). Diagnostic criteria. Inclusion: confirmed asthma diagnosis, no other nonatopic diseases or psychiatric disorders. Diagnosis: mild to moderate asthma. Experimental design. Between groups, AB. Assignment: matched by age, sex, date of asthma onset, and asthma severity. Baseline. One pre-treatment assessment. Assessment measures. Physiological variables: asthma attack episodes, weekly asthma diary, Pulmonary

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Function (e.g., FEV1 pre and post each session). Other variables: Self-Report of State Anxiety. Treatment protocol. Self-Management (SM) program (session content tabled in article) 6 weekly 1-hour sessions, patient and parent; PMR (described by Bernstein & Borkovec, 1973). Treatment 1: SM 1 PMR; control: SM only. Results. Physiological variables: no change in pulmonary function variables post-relaxation. Other variables: self-report of state anxiety decreased after training sessions. Follow-up (Results). None. Vazquez, I., & Buceta, J. (1993b). Psychological treatment of asthma: Effectiveness of a self-management program with and without relaxation training. Journal of Asthma, 30, 171–183. Sample. N 5 27 (30% female, 8–13 years old, mean age 10.8 years). Treatment group (n 5 9); control groups 1 (n 5 9) and 2 (n 5 9). Diagnostic criteria. As in Vazquez & Buceta (1993a). Experimental design. As in Vazquez & Buceta (1993a). Baseline. One pre-treatment assessment. Assessment measures. Physiological variables: as in (1993a). Other variables: as in (1993a), school absences, emergency treatment. Treatment protocol. Self-Management (as in 1993a) PMR (as in 1993a). Treatment 1: SM only. Treatment 2: SM 1 PMR. Control: wait list. Results. Physiological variables: no changes in clinical or pulmonary function variables; PMR did not improve efficacy of treatment. Other variables: selfmanagement encouraged parent-reported asthma care behavior. Follow-up (Results). None. Vazquez, I., & Buceta, J. (1993c). Relaxation therapy in the treatment of bronchial asthma: Effects on basal spirometric values. Psychotherapy & Psychosomatics, 60, 106–112. Sample. As in Vazquez & Buceta (1993b). Diagnostic criteria. As in Vazquez & Buceta (1993a). Experimental design. As in Vazquez & Buceta (1993a). Baseline. One pre-treatment assessment.

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Assessment measures. Physiological variables: as in (1993b). Other variables: trait anxiety questionnaire, emotional trigger interview.

Sample. N 5 5 (20% female, 100% white, 10–16 years old, mean age 5 11.8 years). Treatment group (n 5 4); control group (n 5 1).

Treatment protocol. Self-Management (as in 1993a) PMR (as in 1993a). Treatment 1: SM only. Treatment 2: SM 1 PMR. Control: wait list.

Diagnostic criteria. Inclusion: 10–16-years-old children hospitalized for asthma. Diagnosis: asthma, by pulmonary function testing.

Results. Physiological variables: emotionally triggered (ET) asthma 3 group interaction affects attack duration (ET subjects show greater decrease than non-ET subjects in the SM 1 R group); all pulmonary function variables affected by ET 3 time interaction.

Experimental design. Within subjects, AB design.

Follow-up (Results). None. Biofeedback Davis, M. H., Saunders, D. R., Creer, T. L., & Chai, H. (1973). Relaxation training facilitated by biofeedback apparatus as a supplemental treatment in bronchial asthma. Journal of Psychosomatic Research, 17, 121–128. Sample. N 5 24 (6–15 years old). Diagnostic criteria. Inclusion: 6–15-year-old inpatients in residential program for children with asthma. Diagnosis: asthma. Experimental design. Between groups, AB. Assignment: 3 equal groups matched for age and severity. Baseline. Eight days, 3 measurements per day. Assessment measures. Physiological variables: PEFR (21 days, 3 times daily). Other variables: mood adjective checklist. Treatment protocol. Treatment 1: biofeedback-assisted PMR (study-specific, not well outlined). Treatment 2: PMR without biofeedback. Control: sit quietly, relax. Results. Physiological variables: PEFR improves for treatment 1, but only for nonsevere subjects with asthma.

Baseline. Thirty minutes of “rest,” not necessarily pre-treatment. Assessment measures. Physiological variables: PEFR, maximum mid-expiratory flow rate (MMEF), total respiratory resistance (TRR). Treatment protocol. Biofeedback to decrease total respiratory resistance (study specific), 3–9 sessions. Control: nonasthmatic individual, same treatment. Results. Physiological variables: MMEF%, TRR% improves in all asthma subjects; changes equal to those from medication; no change in PEFR; no change from rest alone. Follow-up (Results). None. Kotses, H., Glaus, K. D., Bricel, S. K., Edwards, J. E., & Crawford, P. L. (1978). Operant muscular relaxation and peak expiratory flow rate in asthmatic children. Journal of Psychosomatic Research, 22, 17–23. Sample. N 5 40 (30% female, mean age 5 11.3 years). Treatment groups 1 (n 5 10) and 2 (n 5 10); control groups 1 (n 5 10) and 2 (n 5 10). Diagnostic criteria. Inclusion: randomly drawn from summer camp attendees. Diagnosis: asthma (severity 5 predicted PEFR - average PEFR scores taken the week before intervention). Experimental design. Between groups (yoked controls), AB. Assignment: 4 equal groups matched for age, sex, and asthma severity, random assignment of groups to conditions. Baseline. One pre-treatment assessment.

Follow-up (Results). None.

Assessment measures. Physiological variables: highest of 3 PEFR measures. Other variables: frontalis electromyography (EMG), brachioradialis EMG.

Feldman, G. M. (1976). The effect of biofeedback training on respiratory resistance of asthmatic children. Psychosomatic Medicine, 38, 27–34.

Treatment protocol. Treatment 1: frontalis relaxation, contingent feedback. Treatment 2: brachioradialis relaxation, contingent feedback. Controls 1 and 2: yoked to above, with noncontingent feedback. All


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receive: 9 sessions (three 10-minute sessions for 3 weeks).

Experimental design. Between groups, AB. Assignment: random.

Results. Physiological variables: increased PEFR in treatment 1 vs. control 1; no PEFR differences between treatment 2 and control 2. Other variables: conditioned frontalis muscle relaxation supported.

Baseline. Four pre-treatment assessments over 4 weeks.

Follow-up (Results). None. Kotses, H., Glaus, K. D., Crawford, P. L., Edwards, J. E., & Scherr, M. S. (1976). Operant reduction of frontalis EMG activity in the treatment of asthma in children. Journal of Psychosomatic Research, 20, 453–459. Sample. N 5 36. Treatment group (n 5 12); control groups 1 (n5 12) and 2 (n 5 12). Diagnostic criteria. Inclusion: children attending summer asthma camp. Diagnosis: asthma, diagnosed by allergist. Experimental design. Between groups. Assignment: matched by age and sex, then random assignment. Baseline. None. Assessment measures. Physiological variables: PEFR (3 times daily during treatment). Treatment protocol. Treatment: biofeedback to reduce frontalis muscle tension (study-specific), one-half hour 3 times per week for 3 weeks. Control 1: Same as above, but noncontingent feedback. Control 2: no treatment. Results. Physiological variables: greater improvement in treatment group vs. control 1; PEFR improved in all subjects. Other variables: reduced EMG frontalis activity for treatment group only. Follow-up (Results). None. Kotses, H., Harver, A., Segreto, J., Glaus, K. D., Creer, T. L., & Young, G. (1991). Long-term effects of biofeedback-induced facial relaxation on measures of asthma severity in children. Biofeedback and Self-Regulation, 16, 1–21.

Assessment measures. Physiological variables: facial EMG, lung functions (e.g., PEFR), weekly asthma diary, self-rated severity. Other variables: Asthma Attitude Survey (parent, child), State/Trait Anxiety Inventory, Piers-Harris Self-Concept Scale. Treatment protocol. Treatment: biofeedback to reduce facial muscle tension (study-specific) one-half hour weekly for 8 weeks. Control: biofeedback for facial muscle tension stability, 8 weekly sessions. Results. Physiological variables: by session 6, groups 3 sessions interaction on EMG; higher pulmonary scores in treatment group. Other variables: more positive attitudes toward asthma, lower chronic anxiety in treatment group; no other differences. Follow-up (Results). Changes stable at long-term follow-up; pulmonary changes observed in lab not reflected in home peak flow values. Scherr, M. S., Crawford, P. L., Sergent, C. B., & Scherr, C. A. (1975). Effects of biofeedback techniques on chronic asthma in a summer camp environment. Annals of Allergy, 35, 289–295. Sample. N 5 44 (38% female, 6–15 years old). Treatment group (n 5 22); control group (n 5 22). Diagnostic criteria. Inclusion: children attending summer asthma camp. Diagnosis: asthma, diagnosed by allergist. Experimental design. Between groups. Assignment: matched by age and sex, then random. Baseline. None. Assessment measures. Physiological variables: PEFR (3 times daily during treatment), medical records from camp (e.g., infirmary visits). Other variables: behavior ratings, mood questionnaire.

Sample. N 5 29 (31% female, 7–16 years old, mean age 5 11.7 years). Treatment group (n 5 15); control group (n 5 14).

Treatment protocol. Treatment: biofeedback-assisted relaxation training (Jacobsonian; study specific) 3 times per week for 5 weeks. Control: camp intervention only.

Diagnostic criteria. Inclusion: 7–16 years old. Diagnosis: mild to severe asthma diagnosed by pediatric pulmonologist.

Results. Physiological variables: fewer infirmary visits and asthma attacks in treatment group; when steroid use controlled, age, group status (treatment

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vs. control), and infirmary visits contributed to asthma severity ratings. Follow-up (Results). None. Family Therapy Gustafsson, P. A., Kjellman, N. I. M., & Cederblad, M. (1985). Family therapy in the treatment of severe childhood asthma. Journal of Psychosomatic Research, 30, 369–374. Sample. N 5 17 (100% white, 6–15 years old, mean age 5 9 years). Treatment group (n 5 9); control group (n 5 8). Diagnostic criteria. Inclusion: no other illness. Diagnosis: severe asthma. Experimental design. Between groups, AB. Assignment: random. Baseline. Three pre-treatment assessments over 8 months. Assessment measures. Physiological variables: PEFR, compliance rating, beta-agonist, steroid use. Other variables: emergency room inpatient days, emergency room visits, days of functional impairment. Treatment protocol. Treatment: family therapy (referenced) exploring role of illness (2–21 sessions, mean 5 8.8, median 5 8.0). Control: regular clinic care. Results. Physiological variables: greater improvement in pediatric assessment for treatment group vs. control; pre-post differences on multiple disease measures for treatment group. Follow-up (Results). No significant changes in disease activity found 18 months after therapy. Lask, B., & Matthew, D. (1979). Childhood asthma: A controlled trial of family psychotherapy. Archives of Disease in Childhood, 54, 116–119. Sample. N 5 29 (,50% females, 4–14 years old). Treatment group (n 5 18); control group (n 5 11). Diagnostic criteria. Inclusion: moderate to severe asthma. Diagnosis: moderate to severe asthma. Experimental design. Between groups, AB. Assignment: random.

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Baseline. Daily recordings over 6 weeks. Assessment measures. Physiological variables: PEFR (a.m. & p.m.), FEV, TGV. Other variables: diary cards measuring day wheeze and activity limitation, psychological assessment. Treatment protocol. Treatment: family therapy (referenced). Six sessions during clinic visit (clinician and qualifications not reported), treatment described in Lask (1979). Control: regular clinic care. Results. Physiological variables: improved in treatment group; no change in FEV; TGV decreased in treatment group. Other variables: no differences in activity limitation; treatment group reported less wheezing. Follow-up (Results). None.

Appendix 2 Description of reviewed studies and treatment outcomes for IDDM (by intervention) Psychoanalysis Moran, G. S., & Fonagy, P. (1987). Psychoanalysis and diabetic control: A singlecase study. British Journal of Medical Psychology, 60, 357–372. Sample. Thirteen-year-old female. Diagnostic criteria. Inclusion: 5 years post-diagnosis. Diagnosis: IDDM Experimental design. Single case, time series correlational analysis. Baseline. None. Assessment measures. Physiological variables: weekly urine glucose content (percentage of 14 urine tests/ week showing ,1% glycosuria). Treatment protocol. Psychoanalysis (described) 740 sessions (5 times per week for 148 weeks). Results. Physiological variables: 2 of 4 conflictual themes correlated with increased tests of ,1% glycosuria 1–4 weeks later. Follow-up (Results). None. Moran, G. S., Fonagy, P., Kurtz, A., Bolton, A., & Brook, C. (1991). A controlled study


of the psychoanalytic treatment of brittle diabetes. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 926–935. Sample. N 5 22 (64% female, 7–19 years old, mean age 5 13.7 years). Treatment group (n 5 11); control group (n 5 11). Diagnostic criteria. Inclusion: 6–18 years old, IDDM . 2 years (mean 5 5.9 years), no psychotic or learning disorder. Diagnosis: IDDM (diagnosis of brittle IDDM). Experimental design. Between groups, AB. Assignment: nonrandom, based on ward to which patient admitted. Baseline. One pre-treatment assessment. Assessment measures. M-value, HbA1c.

Physiological

variables:

Treatment protocol. Psychoanalysis (analysts $ 5 years experience; manualized 45-min sessions, 3–5 times per week (M 5 15 weeks). Control: IDDM education, staff management.

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Treatment protocol. Social Skills Training (limited description) approximately 10 sessions (45 min, 2 times per week for 5 weeks). Results. Physiological variables: no results reported. Other variables: improved social skills in treatment group from baseline to final training session. Follow-up (Results). Physiological variables: 1 assessment (7 weeks post-treatment); no HbA1c change from baseline or group difference. Other variables: 2 assessments (1 and 6 weeks post-treatment); results maintained. Kaplan, R. M., Chadwick, M. W., & Schimmel, L. E. (1985). Social learning intervention to promote metabolic control in Type 1 diabetes mellitus: Pilot experiment results. Diabetes Care, 8, 152–155. Sample. N 5 21 (62% female, 100% white, 13–18 years old, mean age 5 14.5 years). Treatment group (n not stated); control group (n not stated). Diagnostic criteria. Inclusion: diabetes school attendance. Diagnosis: IDDM.

summer

Results. Physiological variables: M-value at hospital discharge lower in treatment vs. control group.

Experimental design. Between groups. Assignment: random, stratified by gender.

Follow-up (Results). Two assessments (3 and 12 months post-treatment). Physiological variables: HbA1c lower than at baseline in treatment group; percentage with reduced HbA1c greater in treatment vs. control group.

Baseline. One pre-treatment assessment.

Social Skills Training

Treatment protocol. Social Skills Training (described) approximately 15 sessions (daily for 3 weeks). Control: information, education.

Gross, A. M., Heimann, L., Shapiro, R., & Schultz, R. M. (1983). Children with diabetes: Social skills training and Hemoglobin A1c levels. Behavior Modification, 7, 151–164. Sample. N 5 11 (9–12 years old). Treatment group (n 5 6); control group (n 5 5). Diagnostic criteria. Inclusion: $ 3 social skill deficits. Diagnosis: IDDM. Experimental design. Between groups, multiple baseline across behaviors. Assignment: random. Baseline. One pre-treatment assessment. Assessment measures. Physiological variables: HbA1c. Other variables: Diabetes Assertiveness Test.

Assessment measures. Physiological variables: HbA1c. Other variables: Rand Corporation Scales: Sarason Social Support Questionnaire, Means-Ends Problem Solving Test.

Results. No results reported immediately following treatment. Follow-up (Results). One assessment (4 months posttreatment). Physiological variables: lower HbA1c in treatment vs. control group. Other variables: IDDM behavior correlated with better HbA1c; social support and problem solving correlated with worse HbA1c. Stress Management Training Boardway, R. H., Delamater, A. M., Tomakowsky, J., & Gutai, J. P. (1993). Stress management training for adolescents

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with diabetes. Journal of Pediatric Psychology, 18, 29–45.

relaxation tape 3 times per week. A-C: Personality and IQ tests.

Sample. N 5 19 (58% female, 68% white, mean age 5 14.8 years). Treatment group (n 5 9); control group (n 5 10).

Results. Physiological variables: post-treatment mean urine glucose percentages lower than at baseline and A-C. Other variables: no changes in anxiety.

Diagnostic criteria. Inclusion: 12–17 years old, IDDM . 1 year, no mental retardation. Diagnosis: IDDM (h/o non-compliance, poor control). Experimental design. Between groups, AB. Assignment: random. Baseline. One pre-treatment assessment. Assessment measures. Physiological variables: HbA1c, fructosamine. Other variables: Diabetes Stress Questionnaire, Ways of Coping Checklist, Self-efficacy for Diabetes Scale, Life Events Checklist.


Appendix 3 Description of reviewed studies and treatment outcomes for cancer (by intervention) Imagery and active cognitive distraction with relaxation

Treatment protocol. Stress Management Training (session topics provided), 13 group sessions (10 over 12 weeks then 3 monthly sessions). Control: routine clinic care.

Cotanch, P., Hockenberry, M., & Herman, S. (1985). Self-hypnosis as antiemetic therapy in children receiving chemotherapy. Oncology Nursing Forum, 12, 41–46.

Results. Physiological variables: no differences in HbA1c or fructosamine between groups. Other variables: less post-treatment diabetes stress in treatment vs. control group.

Sample. N 5 12 (33% female, 9–18 years old). Treatment group (n 5 6); control group (n 5 6).

Follow-up (Results). Two assessments (6 and 9 months post-treatment). Physiological variables: no differences in HbA1c or fructosamine between groups. Rose, M. I., Firestone, P., Heick, H. M. C., & Faught, A. K. (1983). The effects of anxiety management training on the control of juvenile diabetes mellitus. Journal of Behavioral Medicine, 6, 381–395. Sample. N 5 6 (100% female, 15–18 years old). Diagnostic criteria. Inclusion: IDDM . 3 years. Diagnosis: IDDM (poor control). Experimental design. Multiple baseline across subjects. Baseline. Range: 21–54 days; followed by attentioncontrol (A-C) condition (range: 14–29 days). Assessment measures. Physiological variables: urine glucose content, glucose homeostasis. Other variables: Multifactorial Scale of Anxiety, Expectancy for Improvement. Treatment protocol. Anxiety Management Training (not described), 7 hours over first 2 weeks of phase,

Diagnostic criteria. Inclusion: Chemo requiring 48-hr hospitalization, matched chemo courses. Diagnosis: Cancer (67% sarcoma). Experimental design. Between groups, AB. Assignment: random. Baseline. Unclear. Assessment measures. Physiological variables: nausea (amount, duration, intensity), vomiting (amount, frequency, intensity). Other variables: Modified Pain Perception Profile. Treatment protocol. Imagery with hypnotic suggestion (described) 1 session (30–40 min between baseline & f/u chemo courses). Control: cognitive distraction with relaxation. Results. Physiological variables: post-treatment vomiting frequency, amount, severity, and duration lower in treatment vs. control group; posttreatment nausea intensity and duration lower in treatment vs. control group; lower percentage in treatment vs. control group vomit post-treatment. Follow-up (Results). None beyond 2 post-treatment chemo courses. Ellenberg, L., Kellerman, J., Dash, J., Higgins, G., & Zeltzer, L. (1980). Use of hyp-


nosis for multiple symptoms in an adolescent girl with leukemia. Journal of Adolescent Health Care, 1, 132–136. Sample. Sixteen-year-old white female. Diagnostic criteria. Inclusion: 4 years post-diagnosis. Diagnosis: chronic myelogenous leukemia. Experimental design. Single case, AB design. Baseline. One chemo course. Assessment measures. Physiological variables: nausea and vomiting (frequency and intensity). Other variables: acute and chronic pain, anorexia, fever. Treatment protocol. Imagery with hypnotic suggestion (described) prior to second chemo course. Results. Physiological variables: nausea and vomiting frequency reduced during post-treatment chemo course. Other variables: acute and chronic pain reduced during post-treatment chemo course. Follow-up (Results). None. Kaufman, K. L., Tarnowski, K. J., & Olson, R. (1989). Self-regulation treatment to reduce the aversiveness of cancer chemotherapy. Journal of Adolescent Health Care, 10, 323–327. Sample. Eleven-year-old male. Diagnostic criteria. Inclusion: moderately to highly emetogenic chemo regimen. Diagnosis: Wilm’s tumor, stage III. Experimental design. Single case, AB design. Baseline. One chemo course. Assessment measures. Physiological variables: vomiting frequency, nausea. Other variables: hours slept night prior to chemo. Treatment protocol. Imagery with hypnotic suggestion (described), 2 sessions (over 1 week prior to chemo) with daily practice. Results. Physiological variables: .3/4 reduction in vomiting prior to, during, and post-chemo; decrease in self-reported nausea. Other variables: . 175% increase in hours slept night prior to chemo. Follow-up (Results). Four post-treatment assessments (i.e., post-treatment chemo courses). Physiological variables: results maintained. Other variables: results maintained.

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LeBaron, S., & Zeltzer, L. (1984). Behavioral intervention for reducing chemotherapy-related nausea and vomiting in adolescents with cancer. Journal of Adolescent Health Care, 5, 178–182. Sample. N 5 8 (10–17 years old, mean age 5 12.1 years). Diagnostic criteria. Inclusion: 1–78 months post-diagnosis, chemo side effects, consistent chemo protocol. Diagnosis: cancer (63% leukemia). Experimental design. Within subjects, AB design. Baseline. Two to three chemo courses. Assessment measures. Physiological variables: nausea, vomiting. Other variables: bothersome-ness of nausea and vomiting, activity disruption. Treatment protocol. Cognitive distraction with muscle relaxation (described) implemented over 2–3 chemo courses. Results. Physiological variables: nausea and vomiting ratings reduced. Other variables: activity disruption and bothersomeness of nausea and vomiting reduced. Follow-up (Results). None. Zeltzer, L. K., Dolgin, M. J., LeBaron, S., & LeBaron, C. (1991). A randomized, controlled study of behavioral intervention for chemotherapy distress in children with cancer. Pediatrics, 88, 34–42. Sample. N 5 54 (52% female, 65% Hispanic, 5–17 years old, mean age 5 11.7 years). Treatment group 1 (n 5 21); treatment group 2 (n 5 16); control group (n 5 17). Diagnostic criteria. Inclusion: mean time since diagnosis 5 15.8 months, .3 on 10-point scale of chemo-related nausea/vomiting, consistent chemo protocol over .1 courses. Diagnosis: cancer (63% solid tumors). Experimental design. Between groups, AB. Assignment: random. Baseline. One chemo course. Assessment measures. Physiological variables: anticipatory nausea and vomiting, post-chemo nausea and vomiting (duration and severity). Other variables: distress, disruption of eating, sleep, school, play (functional score).

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Treatment protocol. Treatment 1: imagery with hypnotic suggestion (referenced), 1 session (15–30 min) 1 5–15 min at next chemo. Treatment 2: cognitive distraction with relaxation (15–30 min during next chemo). Control: conversation (15–30 min). Results. Physiological variables: nausea duration shorter in treatment 1 and treatment 2 vs. controls; vomiting duration shorter in treatment 1 vs. controls; no differences in nausea and vomiting severity. Other variables: no group differences.

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Sample. N 5 19 (6–17 years old, mean age 5 11.3 years). Treatment group (n 5 9); control group (n 5 10). Diagnostic criteria. Inclusion: mean time since diagnosis 5 9.8 months, nausea and vomiting present, consistent chemo courses. Diagnosis: cancer (58% leukemia). Experimental design. Within subjects, AB. Assignment: random, age and chemo agents accounted for.


Baseline. Two chemo courses.

Zeltzer, L., Kellerman, J., Ellenberg, L., & Dash, J. (1983). Hypnosis for reduction of vomiting associated with chemotherapy and disease in adolescents with cancer. Journal of Adolescent Health Care, 4, 77–84.

Assessment measures. Physiological variables: nausea and vomiting severity. Other variables: bothersomeness of nausea and vomiting, Stanford Hypnotic Scale for Children.

Sample. N 5 12 (42% female, mean age 5 14.2 years). Diagnostic criteria. Inclusion: mean time since diagnosis 5 27.3 months. Diagnosis: cancer (33% Hodgkin’s disease). Experimental design. Within subjects, AB design. Baseline. One chemo course. Assessment measures. Physiological variables: vomiting (daily intensity, frequency, and duration). Other variables: Spielberger Trait Anxiety Scale, Rosenberg Self-esteem Scale, Wallston Health Locus of Control Scale, Impact of Illness Scale. Treatment protocol. Imagery with hypnotic suggestion (described) 1–3 sessions prior to and during post-baseline chemo course. Results. Three of eleven subjects “reject” hypnosis. Physiological variables: vomiting frequency and intensity of reduced in remaining subjects. Follow-up (Results). One assessment (6 months posttreatment). Physiological variables: not assessed. Other variables: anxiety in treatment group reduced from baseline. Zeltzer, L., LeBaron, S., & Zeltzer, P. M. (1984). The effectiveness of behavioral intervention for reduction of nausea and vomiting in children and adolescents receiving chemotherapy. Journal of Clinical Oncology, 2, 683–690

Treatment protocol. Imagery with hypnotic suggestion (referenced) 1 session (approx. 30 min) 1 therapist at chemo. Control: cognitive distraction with relaxation (same schedule as treatment group). Results. Physiological variables: nausea and vomiting severity reduced in both groups from baseline to treatment; 75% decrease antiemetics. Other variables: bothersomeness of symptoms reduced in both groups from baseline to treatment. Follow-up (Results). One assessment. Physiological variables: results maintained. Other variables: results maintained; subject reduction in treatment group not related to hypnotic susceptibility score. Video Games Kolko, D. J., & Rickard-Figueroa, J. L. (1985). Effects of video games on the adverse corollaries of chemotherapy in pediatric oncology patients: A single-case analysis. Journal of Consulting and Clinical Psychology, 53, 223–228. Sample. N 5 3 (0% female, 11–17 years old, mean age 5 14.7 years). Diagnostic criteria. Inclusion: none noted. Diagnosis: cancer (100% ALL). Experimental design. Multiple baseline across subjects, ABAB. Baseline. First baseline: 3–5 chemo sessions; second baseline: 3 chemo sessions. Assessment

measures.

Physiological

variables:


Modified-Procedure Behavior Rating Scale, Chemotherapy Experience Schedule. Other variables: 24-hour Symptom Checklist, State/Trait Anxiety Inventory. Treatment protocol. Video Game Access (described) 3 chemo courses baselines: clinic resources (e.g., TV). Results. Physiological variables: behavioral distress just prior to chemo and post-chemo reduced during treatment phases. Other variables: anticipatory sxs reduced during treatment phases. Follow-up (Results). None. Redd, W. H., Jacobsen, P. B., Die-Trill, M., Dermatis, H., McEvoy, M., & Holland, J. C. (1987). Cognitive/attentional distraction in the control of conditioned nausea in pediatric cancer patients receiving chemotherapy. Journal of Consulting and Clinical Psychology, 55, 391–395. [This study and the following study by the same authors were reported in the same article.] Sample. N 5 26 (27% female, 9–20 years old, mean age 5 14 years). Treatment group (n 5 13); control group (n 5 13). Diagnostic criteria. Inclusion: $ 9 years old, conditioned nausea, able to provide self-reports. Diagnosis: cancer (42% sarcoma). Experimental design. Between groups, AB. Assignment: alternate assignment. Baseline. One pre-treatment assessment. Assessment measures. Physiological variables: nausea (severity), pulse rate, diastolic blood pressure. Other variables: anxiety (severity rating). Treatment protocol. Video Game Access (described) 2 sessions (10 min each), baselines: clinic resources (10 min). Results. Physiological variables: nausea severity decreased during sequential treatment periods relative to respective baselines. Other variables: no changes in anxiety. Follow-up (Results). None. Redd, W. H., Jacobsen, P. B., Die-Trill, M., Dermatis, H., McEvoy, M., & Holland, J. C. (1987). Cognitive/attentional distraction in the control of conditioned nausea

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in pediatric cancer patients receiving chemotherapy. Journal of Consulting and Clinical Psychology, 55, 391–395. [This study and the previous study were reported in the same article.] Sample. N 5 15 (27% female, 9–18 years old, mean age 5 12.7 years). Diagnostic criteria. Inclusion: from previous study. Diagnosis: cancer (40% leukemia). Experimental design. Within subjects, ABAB withdrawal. Baseline. One pre-treatment assessment, 1 assessment when intervention withdrawn. Assessment measures. Physiological variables: nausea (severity). Treatment protocol. Video Game Access (described) 1 session (10 min), control: clinic resources. Results. Physiological variables: nausea severity decreased in treatment group from baseline to treatment. Follow-up (Results). None.

Acknowledgments This work was supported in part by a grant from the American Lung Association (CG-002) to Dr. McQuaid. We thank Sheryl Kopel and Jennifer Sousa for their valuable assistance during preparation of this manuscript. Received December 12, 1997; accepted October 2, 1998

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