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DOI: 10.1177/000992288702601105

1987 26: 581CLIN PEDIATRMark Scott Smith and William M. Womack

Meditation, Hypnosis, and Biofeedback: Appropriate Clinical ApplicationsStress Management Techniques in Childhood and Adolescence: Relaxation Training,

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581

Stress Management Techniques in Childhoodand Adolescence

Relaxation Training, Meditation, Hypnosis, and Biofeedback:Appropriate Clinical Applications

Mark Scott Smith, MD,* William M. Womack, MD

From the Departments of * Pediatrics and Child Psychiatry andBehavioral Medicine and Behavioral Sciences, University of Wash-ington School of Medicine, Seattle, Washington.Correspondence to: Mark Scott Smith, MD, Chief, Adolescent

Services, Childrens Orthopedic Hospital, 4800 Sand Point Way,NE, P.O. Box C5371, Seattle, WA 98105.Received for publication December 1986, revised March 1987,

and accepted April 1987.

Many childhood and adolescent stress-related symptoms have a psychophysiological compo-nent that involves muscular tension and/or autonomic nervous system dysfunction. Examples ofthis include recurrent headache, chest pain, abdominal pain, syncope, and dizziness. After acareful medical and psychosocial evaluation, the clinician may identify many patients who areappropriate for the application of stress reduction techniques such as progressive muscularrelaxation, meditation, biofeedback, and relaxation/mental imagery (self-hypnosis). This re-view describes these techniques and their application with selected children and adolescents.

CHILDREN AND ADOLESCENTS often mani-fest symptoms that appear to have a strong psycho-physiological component. It has become popular torefer to predisposing conditions that precipitate suchsymptoms as &dquo;stress.&dquo;

1

Symptoms such as recurrent headache, chest pain,abdominal pain, syncope, or dizziness must be evalu-ated in a comprehensive manner to rule out signifi-cant organic disorders as well as psychosocial prob-lems such as physical and sexual abuse, substanceabuse, and fear of pregnancy. Particular attentionshould be paid to the child or adolescents relation-ship with family, school, peers, and community. Dys-function in any of these areas may be related to the

presence of psychophysiological symptoms. Anxietydisorders may present with a multitude of symptomsreflecting both voluntary and autonomic nervoussystem hyper-reactivity. Depression is commonly as-sociated with somatization.4The importance of a careful history and physical

examination with particular attention to the aboveconsiderations cannot be overemphasized. Prior toembarking on a behavioral approach to a presumedpsychophysiological symptom (e.g., tension head-ache), organic disorders must be adequately ruledout (e.g., slowly growing craniopharyngioma).Some diagnoses such as a major depressive dis-

order or sexual abuse require referral to a mentalhealth or social service professional. Often, however,the clinician may determine that stress-related symp-toms are not associated with major psychosocial dis-order and may appropriately be managed in theprimary care setting. Examples of the latter mightinclude muscle contraction headaches in an over-

achieving child, recurrent abdominal pain in a childof a family undergoing divorce or frequent chestpain in an adolescent with anxiety related to school

582

problems. In these situations, brief supportive coun-seling by the primary care clinician coupled with in-struction in stress reduction techniques may provideappropriate cost-effective treatment. This paper isintended to review the use of stress reduction tech-

niques in children and adolescents.

Stress Hypothesis

It is often possible to postulate a plausible physio-logical mechanism associated with the presence ofany given symptom. For example, abdominal painmay be related to dysfunction of intestinal motility oraerophagia; chest pain may be related to hyperventi-lation syndrome with intercostal muscle spasm; andfrequent headaches may be related to prolongedmuscular contraction and vasomotor instability.Children and adolescents and their parents are often

receptive to such explanations and may find themuseful in linking the presence of a symptom with anunderlying stressor. Additionally, such psychophysi-ological explanations provide a basis for the intro-duction of self-control behavioral techniques aimedat symptom reduction.

It appears that the experience of deep relaxation iscommon to most stress-reduction techniques andperhaps an altered state of consciousness is an addi-tional component. An altered state of consciousness

implies that the individual is experiencing a con-scious state somewhat different than their usual one,which is primarily focused on the external environ-ment. The practice of stress reduction techniques in-volves becoming more absorbed in internal states byfocusing attention or using mental imagery. Progres-sive muscular relaxation, meditation, hypnosis, andbiofeedback have been shown to be effective in re-

ducing psychophysiological symptoms in childrenand adolescents.5-8

Since it has been difficult to demonstrate the supe-riority of one technique over another and individualchildren and adolescents may have a preference for aparticular method, it is useful for the clinician tohave knowledge of several behavioral techniques forstress reduction. As with any effective treatment,

rapport with the patient, suggestion, expectation ofrelief, treatment credibility, and compliance are im-portant factors in successful interventions. Moderateto severe depression may prevent successful patientinvolvement.

Stress Reduction Techniques

Relaxation Training

Progressive muscular relaxation teaches one to beaware of varying degrees of muscle tension through-out the body.9 Through a series of exercises alter-nately tensing and relaxing various muscle groups, adeep state of relaxation is produced. Particular em-phasis is placed on perceiving the transition frommuscular tension to relaxation. The process is re-

peated with successive muscle groups throughout thebody until deep muscular relaxation is achieved. Ab-breviated versions of Jacobsons original techniquehave been developed that can be completed in ap-proximately 15 minutes.lO,1lThe progressive muscular relaxation technique

does not require mental imagery or special equip-ment and the rationale for its use is understood bymost patients. The following case illustrates the useof the progressive muscular relaxation technique.A 15-year-old girl undergoing chemotherapy for

a lymphoma began to experience extreme anxietyeach time intravenous therapy was instituted. Shedescribed many kinesthetic sensations during theseepisodes which included coldness of the extremities,abdominal discomfort, &dquo;goosebumps,&dquo; and tachycar-dia. Although she was unable to use mental imagerytechniques successfully, she was very receptive to theprogressive muscular relaxation technique. With se-quential tensing and relaxing of various musclegroups and attention to the consequent sensationsover a 15-minute period, she was able to attain astate of deep relaxation and decreased anxiety. Shewas able to tolerate subsequent intravenous proce-dures without undue anxiety while listening to a taperecording of the technique.

Meditation

Meditation has been part of Eastern and Western

spiritual practice for centuries. Only recently hasmeditation been applied to the management of medi-cal disorders. 2,1 Although it is often used in spiri-tual development, the practice of meditation re-quires no particular belief system. The type that ismost applicable to the medical setting is concentra-tive meditation. This involves narrowly focusing theattention of the mind onto a sound or symbol.

583

Transcendental meditation has been shown to be

associated with decreased oxygen consumption, car-bon dioxide production, respiratory rate, and mi-nute ventilation.&dquo; Benson demystified the techniqueand instructed subjects in the use of a simple medita-tive technique using the word &dquo;one.&dquo;15 Bensontermed this technique the relaxation response. In-structions for use of the relaxation response are sim-

ple : 1) Sit quietly; 2) Close your eyes; 3) Deeply relaxall your muscles; 4) Become aware of your breathing;5) Each time you exhale say the word &dquo;one&dquo; (or an-other word of your choosing) silently to yourself; 6)If distracting thoughts enter your mind, simplybrush them aside and return to repeating the word&dquo;relax;&dquo; 7) Do not evaluate your performance; 8)When 20 minutes has passed, sit quietly for a fewmoments, then gently and slowly open your eyes.Meditation is a relatively passive technique and re-

quires acceptance on the part of the subject. Someadolescents, particularly those who have had experi-ence with martial arts techniques, find the concept ofmeditation intriguing.A 17-year-old male with mild hypertension rang-

ing from 140 to 150 over 90 during a 6 month pe-riod was evaluated medically and found to have es-sential hypertension. He had experience with karatetraining and was receptive to the idea of using a med-itation technique. He was instructed in the relaxationresponse as described by Benson and encouraged inhis belief in &dquo;mind control&dquo; techniques. He practicedthe technique for 15 minutes twice daily, and over aperiod of several months his blood pressure normal-ized. At a 6 month follow-up he was normotensiveand reported continued practice of the meditationtechnique, which he enjoyed.

HypnosisClinical hypnosis usually involves relaxation and

the use of mental imagery. For this reason, and be-cause of the stigma attached to the word, hypnosishas been termed relaxation-mental imagery by someauthors.&dquo; Gardner has aptly defined hypnosis as &dquo;astate of heightened concentration in which the pa-tient who is willing and motivated may experiencealterations in sensations and perceptions and may bemore responsive to suggestions from the therapistwhich are consistent with the patients ownwishes.&dquo;17 In hypnosis there is a general decrease incritical cognitive function resulting in what Hilgard

has defined as &dquo;subsidence of the planning func-tion.&dquo;18The subject who is receptive to hypnosis focuses

attention on an alternate state of awareness thatallows the acceptance of suggestions promoting per-ception or behavior which is ultimately compatiblewith the subjects desires. During hypnosis, the childor adolescent may achieve relief from symptoms and

additionally receive post-hypnotic suggestions allow-ing continued improvement or relief from symptomsto carry over into the normal waking state. Althoughnot all children and adolescents are good hypnoticsubjects, most receive some benefit from the state ofdeep relaxation that can be achieved. Hypnotic abil-ity (suggestibility) peaks in the pre-adolescent yearsand remains at somewhat lower levels throughoutadolescence.9The clinical use of hypnosis requires some training

and experience. Confidence, enthusiasm, and rap-port generated by the therapist are important inachieving clinical states of hypnosis. The clinical ap-plication of hypnosis is truly an art and there aregenuine masters of this technique. The interestedclinician, however, can achieve adequate competencyin hypnosis by participating in a workshop presentedby a reputable organization such as The AmericanSociety of Clinical Hypnosis or the Society for Clini-cal and Experimental Hypnosis.A 9-year-old boy experienced weekly common

migraine headaches for 3 years. A complete medicalevaluation was normal and the family history waspositive for migraine. He was motivated and recep-tive to instruction in self-hypnosis techniques. Fol-lowing an eye-roll induction technique he visualizedhimself walking through a pile of leaves which wasbeing blown away by the wind as he counted fromten down to zero. He then imagined various sce-narios (e.g., good &dquo;Transformers&dquo; subduing the evilones) that enhanced his sense of mastery and controlover headache mechanisms. After 4 weeks of prac-tice for 15 minutes twice daily, the frequency of hisheadaches decreased markedly. After 2 months ofpractice he experienced only infrequent mild head-aches, and at a 6 month follow-up visit he was head-ache free.

Biofeedback

Biofeedback provides electronic signal detectionof physiological variables such as electromyographic

584

potentials, skin temperature, Galvanic skin response,and electroencephalographic potentials.20,21 Thesesignals are amplified and displayed to the individual,usually as auditory or visual information. Throughthe monitoring of this previously unavailable infor-mation, and the application of what has been termed&dquo;passive volition,&dquo; the subject learns to alter the spe-cific physiological activity.

Skin temperature biofeedback is commonly usedto train subjects in fingertip warming. Since bloodflow to the skin of the hand is predominantly a func-tion of sympathetic nervous system tone, vasodilationand warming involves decreased sympathetic activityin the hand.22 Vigorous and determined efforts toinfluence the skin temperature are usually unsuc-cessful. It is when one is able to achieve a relaxed

passive state of awareness that the desired changeoccurs.

The specificity of biofeedback training is debat-able.2~24 Certainly biofeedback may be used to aug-ment relaxation training and the electronic instru-mentation is often attractive to children and adoles-cents who may be less receptive to simple relaxationor imagery techniques. In addition, the feeling ofmastery and control frequently is reinforced withsuccessful biofeedback training.A 16-year-old girl began experiencing frequent

syncopal episodes followed by throbbing headaches.A complete medical evaluation including CT scan,EEG, and 24 hour Holter monitoring yielded no ab-normal findings. Psychiatric consultation found noevidence for conversion disorder. The patient wasfelt to be experiencing basilar artery migraine withsyncope and multiple trials of anticonvulsants andBeta-blockers were unsuccessful in preventing at-tacks. With a behavioral intervention she had diffi-

culty forming images and was not receptive to simpleprogressive muscular relaxation exercises. She wasintrigued by the temperature biofeedback apparatus,however, and proved to be an excellent subject whocould produce rapid and consistent fingertip warm-ing. She received 6 temperature biofeedback sessionsand practiced home hand-warming techniques usinga liquid crystal temperature band on her fingertip.After several sessions of biofeedback training cou-pled with home practice, she noted a marked de-crease in syncopal episodes. After 6 weeks of trainingshe experienced no further episodes and remainedsymptom free at a 1 year follow-up.

Conclusion

With appropriate patient selection, the primarycare clinician may provide effective therapy for chil-dren and adolescents with symptoms which have a

psychophysiological component. Patients with signif-icant psychological, social, or organic disorders musthave adequate management of the primary problemprior to institution of stress reduction techniques.The successful application of any stress reductiontechnique requires some clinical training and experi-ence. Progressive muscular relaxation and medita-tion techniques are accepted by many children andadolescents and can be learned relatively easily bythe clinician. Effective hypnosis is accomplished onlyafter more extensive training and experience such asthat provided by The American Society of ClinicalHypnosis or The Society for Clinical and Experimen-tal Hypnosis. Biofeedback requires relatively expen-sive equipment and training in its use. There is nosolid evidence that any one technique is superiorover another, although some patients may prefer aparticular method.The successful use of any stress reduction tech-

nique requires rapport with the patient, patient re-ceptivity, expectation of relief from symptoms, fo-cusing, relaxation, and motivation to practice. Stressreduction techniques provide adjunctive therapy toindicated medical and psychological interventions;they are not an appropriate substitute for them. Forexample, providing only a behavioral interventionfor a child with chronic headaches who has an abu-

sive family or who is suffering from a major depres-sive disorder is inadequate therapy. Following a care-ful medical and psychosocial evaluation, the clinicianmay select children and adolescents who are goodcandidates for the application of stress reductiontechniques. These patients may then receive briefsupportive counseling, instruction in an acceptabletechnique, and several short follow-up visits to trou-ble-shoot practice problems and monitor progress.

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