Behavioural strategies for pain management

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Learn about behavioural strategies such as biofeedback and CBT. These strategies can be used for effective pain management for children.

Many behavioural strategies have been shown to reduce pain and disability. Many of these strategies have positive effects on parents as well as children. Behavioural strategies can calm both parent and child, and reduce the need for restraint during procedures such as injections.

Positive reinforcement

Ignoring pain behaviour and positive reinforcement of non-pain behaviour is a simple way of modifying your child’s behaviour. This can be done by making supportive comments during and after painful episodes. Rewarding positive behaviour is a much better strategy than punishing negative behaviour, which will increase your child’s sense of anxiety, helplessness, and pain.

Giving the child a choice

Allowing the child to have a choice and therefore an impact, no matter how modest, on what is going on is another way of increasing their sense of control. For example, if a child needs a blood test, allowing them to make the choice of which arm to use can be calming. However, while most children respond well to this strategy, some children may become anxious when informed or presented with a choice.

Deep breathing

Controlled deep breathing is a highly effective method of coping with pain. Deep breathing encourages positive changes in blood pressure and heart rate and helps children focus and concentrate. Abdominal breathing, or using the tummy to breathe in and out rather than moving the chest, is an excellent technique to achieve relaxation and to focus attention away from pain. It can also be used with imagery techniques such as "blowing the pain away." Each deep breath produces a calming effect and a sense of well-being.

Get your child to begin by breathing out or exhaling to the point of emptying the lungs and then starting a regular rhythm of breathing in and out deeply. If possible, your child should breathe in through the nose and out slowly through the mouth. As your child exhales, they should be encouraged to picture the pain being "blown away" out of their body. With help from parents, even toddlers can be taught deep breathing. Ask your toddler to imagine blowing out birthday candles to get them started. The use of party blowers and blowing on windmills can also achieve the same thing. Children as young as six years old, once taught, can do deep breathing exercises by themselves.


Biofeedback helps a person focus on body processes that they are not usually aware of such as skin temperature or heart rate, and then teaches them to control these processes. With biofeedback, a person can learn to slow down their heart if it is beating fast or to cool down or warm up their skin. Using monitoring machines that give a visual or sound representation of body functions such as blood pressure, heart rate, and muscle activity, children learn to identify and consciously manage their bodies.

Biofeedback can have a direct or indirect effect on pain and can certainly reinforce a child’s sense of control. Although biofeedback often uses complicated electronic equipment, some forms of biofeedback use very simple equipment like temperature-sensitive sticky dots that change colour with temperature. These can easily be used at home. However, biofeedback should first be learned with a trained professional.

Children often delight in seeing changes in heart rate and muscle tension that they themselves have manipulated. To a child, biofeedback is like a magical game. Biofeedback also sends an undeniable message to your child: their mind has much more control over their body than they imagined. This lesson reinforces other behavioural and psychological pain-reduction techniques. Biofeedback therapy is often combined with other relaxation techniques. Once a child is skilled at controlling their body with the help of a therapist, they can begin to apply the techniques in real-life situations without the use of the monitoring equipment.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) helps to identify and change the thinking, behaving, and feeling factors that affect a child’s pain and disability. Usually many factors influence a child’s pain – some factors may trigger an increase in pain intensity and some may prolong disability. Parents’ beliefs guide their behaviours towards their children and often shape their children’s emotional responses to pain. Pain specialists help to identify which factors are relevant for a child and then select the most appropriate cognitive and behavioural therapies to be combined in a counselling program for individual children. Some of the most common cognitive and behavioural therapies have been outlined above.


Distraction is a simple and very effective pain reduction method for infants and children. When a child concentrates on something interesting and enjoyable, they do not feel as much pain. Common techniques include reading a book, helping to tell a story, and playing a video game. The more involved the child is in a distracting activity, the more effective it is. Distraction often involves another person, usually a parent, but it can be something that children can learn to use on their own.

Distraction is not a matter of tricking the child to ignore the pain, it is more like inviting the child to shift their focus from the pain to something more pleasant and interesting. As your child’s attention is diverted to something other than the pain, the pain signals are interrupted. Distraction tends to work best on mild pain, especially a pain familiar to the child. Children get better at distraction with practice.

When combined with regulated deep breathing, discussed on the "Behavioural Strategies" page of this section, distraction can be effective in counteracting procedural pain.

How to distract your child from pain

How you distract your child will depend on their age. Babies can be distracted with colourful mobiles and mirrors. Young children can be distracted with blowing bubbles or party blowers, reading a favourite book, playing with a musical toy or using virtual reality glasses. Older children can choose what they wish to be distracted with: a hand-held video game, for example. Distraction can also be combined with hypnosis and other relaxation techniques.

Imagery and imagination

Imagination is a special form of distraction. It is so natural that it usually comes very easily to young children. To lessen pain, your child should try to imagine some pleasant experience. The idea is that while concentrating on a favourite image or memory, your child will no longer be preoccupied by the pain. As your child focuses on something other than the pain, ask them to describe it using all their senses.

Children rely more on visual images than on other senses, so if a child describes being on a swing in a park, you can gently encourage them by asking about the sound and feel of wind, the smell of the grass and the taste of a treat they may be enjoying. Your encouragement and questions should come slowly in a calm and reassuring voice.

A child can also learn other imagery techniques from a pain specialist, such as imagining letting go of the pain or shrinking it.

These imagination techniques can be adapted to suit your child’s age, temperament and interests. The most important thing is selecting an image or situation that is meaningful and pleasant for them. The more the techniques are used, the better children get at using them. These techniques are best learned with a professional and can then be practised by your child, with or without their parents.​

Last updated: September 15th 2009