Interactive versus Passive Distraction for Acute Pain Management in Young Children

The Role of Selective Attention and Development

Karen A. Wohlheiter; PhD; Lynnda M. Dahlquist; PhD


J Pediatr Psychol. 2013;38(2):202-212. 

In This Article

Abstract and Introduction


Objective To examine whether age and developmental differences in selective attention influence young children's differential responses to interactive and passive distraction.

Methods 65 3- to 6-year-old children underwent three cold-pressor trials while receiving no intervention, playing a video game (interactive distraction), or watching a video game (passive distraction). In addition, children completed a test of selective attention, and parents completed ratings of attention.

Results Consistent with neurocognitive models of pain, children benefited more from interactive distraction than from passive distraction. Although older children demonstrated superior pain tolerance overall, age and selective attention skills did not moderate children's responses to the distraction intervention.

Conclusions These findings suggest that younger preschoolers can benefit from interactive distraction to manage acute pain, provided that the distraction activity is developmentally appropriate. Research is needed to determine whether developmental issues are more important moderators of children's responses to distraction when faced with more challenging task demands.


Although distraction is widely recognized as an effective acute pain management strategy for children (Uman, Chambers, McGrath, & Kisley, 2008), recent research suggests that certain types of distraction tasks may be more effective than others. For example, some studies have demonstrated that interactive distraction, which requires the child to cognitively engage with the distracting stimulus, is more effective than passive distraction, which only requires the child to visually or auditorily observe the distracting stimulus (e.g., Dahlquist, McKenna, Dillinger, Weiss, & Ackerman, 2007; Mason, Johnson, & Wooley, 1999). However, empirical findings are mixed, with some studies finding no differences between interactive and passive distraction (e.g., Weiss, Dahlquist, & Wohlheiter, 2011), and others reporting certain applications of passive distraction to be more effective than some forms of interactive distraction (MacLaren & Cohen, 2005). Methodological limitations, such as the use of interactive and passive tasks that differ on many dimensions other than interactivity (e.g., cartoons vs. electronic games), hinder the interpretation of these discrepant findings (Dahlquist et al., 2007; Weiss et al., 2011).

The hypothesized superiority of interactive distraction is consistent with current neurocognitive and cognitive–affective models of attention and pain that propose that pain is evolutionarily predisposed to interrupt and capture attention and to become a compelling motivation for action and escape behaviors (Eccleston & Crombez, 1999, p. 361). To combat this "bottom up" selection of attention by pain, the individual must deliberately use central cognitive resources to redirect attention away from pain (Eccleston, 1995; Legrain et al., 2009). This "top down," intentional, goal-directed, and effortful process is thought to be activated in working memory (Legrain et al., 2009).

Distraction tasks that involve the intentional and effortful direction of attentional control (i.e., require ongoing central attentional processing), therefore, should be more effective in combating pain than tasks that demand less central cognitive processing (i.e., passive tasks that involve little executive functioning, or repetitive routinized tasks that become automatic, rather than controlled, over time) (Eccleston, 1995; Law et al., 2011). Thus, in theory, interactive distraction should be more effective than passive distraction.

Dahlquist et al. (2007) tested this premise in a tightly controlled comparison of interactive video game distraction (delivered via virtual reality technology) and passive distraction (i.e., watching the same video game footage used in the interactive distraction condition, delivered by the same virtual reality technology) with children aged between 5 and 13 years undergoing cold-pressor pain. They found that both distraction conditions improved the children's pain threshold and pain tolerance scores, and that the interactive distraction condition was significantly more effective than the passive distraction condition.

However, there is some evidence that age may moderate the differential efficacy of interactive versus passive distraction. In the Weiss et al. (2011) study of sixty-one 3- to 5-year-old preschool children, both interactive and passive distraction resulted in improvements in cold-pressor pain tolerance; however, their interactive video game distraction condition did not result in improvement in cold-pressor pain tolerance that was superior to the effect of passively watching the output generated by the same video game.

One possible explanation for the failure to detect a superior effect for interactive distraction in the Weiss et al. (2011) study is that preschool children lack the cognitive skills needed to actively engage with an interactive distraction task when also faced with a competing pain stimulus. Preschool children have more immature executive functioning and central attentional skills than do elementary school-aged children. Preschoolers demonstrate rapid changes in these skills between the ages of 2 and 7 years as the prefrontal cortex matures (Kane & Engle, 2000; Rosen & Engle, 1998; Sinclair & Taylor, 2008). Specifically, selective attention—a prerequisite for the development of sustained attention—begins to develop in early childhood (Hale, 1979). Children develop increased ability to attend to structured tasks such as games between the ages of 3 and 5 years (Ruff, Capozzoli, & Weissburg, 1998). In addition, children's inhibition and set-shifting skills improve during this period such that 5- and 6-year-old children have better selective attention skills than younger preschool-aged children (Espy, 1997).

These developmental differences in selective attention skills may influence how children respond to interactive video game distraction. Video games require children to selectively attend to the game and to follow a specific set of structured rules. Such interactive distraction tasks may not be appropriate for young preschool children or children with comparably immature selective attention skills. In contrast, older preschoolers should be better able to maintain focus on structured interactive tasks, such as video games, when confronted with competing painful stimuli because of their better developed selective attention and inhibition and set-shifting skills. Thus, children aged >4 years may be better able to benefit from interactive distraction tasks than those aged <4 years.

It is also possible that younger children require more extensive training and experience with an interactive distraction task for it to be effective. Weiss et al. (2011) noted that few of their participants had ever played video games. Thus, although the children demonstrated basic mastery of the video game (i.e., ability to maneuver through the game and execute game-relevant activities), they might not have been familiar or competent enough with the video game to sustain attention to the interactive task in the face of pain. The current study addressed this concern by providing children more extensive training in the video game before using it as the interactive distraction task.

Aims and Hypothesis

The primary aims of the study were to understand how age and selective attention skills affect the utility of interactive versus passive distraction for preschool- and early school-aged children experiencing cold-pressor pain. The length of time children tolerated cold-pressor discomfort was compared during baseline (no distraction), interactive distraction (playing a developmentally appropriate video game), and passive distraction (watching prerecorded video game footage from the same video game). We expected that all children would benefit from both distraction interventions relative to baseline (no distraction). In addition, we hypothesized that age and selective attention skills would moderate the effects of the two distraction interventions, with older children and children with better selective attention, inhibition, and set-shifting skills (i.e., attention-related executive functions) showing the greatest differential benefit from interactive distraction relative to passive distraction.