Psychophysiological effects of relaxation training in ...

British Journal of Health Psychology (2001), 6, 197–206 Printed in Great Britain

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© 2001 The British Psychological Society

Psychophysiological effects of relaxation training in children Arnold Lohaus* and Johannes Klein-Heßling University of Marburg, Germany

Claus Vo¨gele University of Luton, UK

Christiane Kuhn-Hennighausen University of Marburg, Germany Objectives. This study compares the effects of progressive muscle relaxation and an imagery-based relaxation training on childrens’ physiological and subjective responses in a randomized controlled trial. Design. Sixty-four children aged 9 to 13 years were randomly allocated to either one of three experimental conditions: progressive muscle relaxation, imagery-based relaxation or a control condition (neutral story). There were ve training sessions in each condition. Method. Heart rate (HR), skin conductance level (SCL), and skin temperature (ST) were measured continuously during a 5-minute baseline period, an 8-minute relaxation training period, and a 5-minute follow-up in each session. In addition, subjective ratings of mood and physical well-being were collected intermittently. Results and conclusions. A physiological pattern indicating relaxation was most clearly associated with the imagery-based relaxation approach (decreases in HR and SCL), although ST remained unchanged. In contrast, progressive muscle relaxation led to an increase in HR during the training. The neutral story condition showed a similar trend as the imagery-based relaxation approach (although not reaching statistical signicance). Furthermore, children’s ratings of positive mood and physical wellbeing increased during baseline and training periods, but there were no differences between training conditions. The results indicate psychophysiological effects of relaxation instructions which, however, are not specic for systematic relaxation training.

The present study addressed the question whether systematic relaxation techniques used with children are associated with psychophysiological effects in the context of primary prevention. Previous studies investigating the usefulness of relaxation techniques in children focus mainly on problems of secondary prevention. For example, relaxation training is successfully used to reduce somatic or psychological symptoms or to support *Requests for reprints should be addressed to Dr Arnold Lohaus, Department of Psychology, University of Marburg, Gutenbergstr. 18, D-35032 Marburg, Germany (e-mail: [email protected]).

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children’s ability to cope with the emotional reactions caused by their illnesses, for instance to cope with headaches (King, Ollendick, Murphy, & Molloy, 1998; Sartory, Mueller, Metsch, & Pothmann, 1998), asthma (Creer, 1991) or anxiety (Armstrong, Collins, Greene, & Panzironi, 1988; Plantania-Solazzo, Field, Blank, & Seligman, 1992; King et al. 1998). Systematic evaluations of the basic effects of relaxation techniques in the context of primary prevention are, however, rare in the literature. Relaxation training is often used to enhance the coping behaviour of children. Lazarus and Folkman (1984) differentiate between problem-focused and emotion-focused coping. Relaxation is assumed to be regulating the emotional and physical responses to stressful events, and can therefore be conceptualized as an emotion-focused strategy. In a study by Spirito and Stark (1991), children aged 6 to 9 mainly used problem-solving strategies, while emotion-regulating strategies were seldom used spontaneously in this age group. The signicance of emotion-regulating strategies seems to increase over age, while problem-solving strategies are used in all age groups and do not show comparable developmental trends. The results of a training study by Lohaus, Klein-Heßling, and Shebar (1997) comparing stress management programmes that focused either on relaxation or on problem solving showed more favourable results for a training programme supporting the problem-solving skills of elementary school children. Thus, younger children may not only use emotion-regulating coping strategies less often in stress situations (as was shown by the study by Spirito & Stark, 1991), but they may also benet less from them (as indicated by the previous training study). In light of these ndings, a second training study (Lohaus & Klein-Heßling, 2000) examined the question whether children benet from relaxation procedures in the context of primary prevention. Over ve training sessions, different relaxation techniques were presented to children to evaluate their effects on a range of criteria. Training conditions included a sensory approach to relaxation (progressive muscle relaxation), an imagerybased relaxation approach, a combined training (with imagery and sensory elements), and two control conditions. In one control condition children listened to non-tension producing stories, whereas children in the second control condition did not receive any specic intervention. The sample consisted of 826 children aged 7 to 14 years. The results show signicant short-term effects on psychophysiological parameters (blood pressure, heart rate, skin temperature) as well as on subjective ratings of children’s mood and physical well-being. In relation to overall changes, however, the observed differences between training conditions were comparatively small. In conclusion, relaxation training was not superior to the presentation of neutral stories in inducing relaxation in children. In the study by Lohaus and Klein-Heßling (2000) psychophysiological responses were not measured continuously but only single readings were taken before and after training sessions. There may be some doubt as to the reliability of such measurements, because responses to taking the readings from a wrist blood pressure device and a thermometer attached to the ear lobe cannot be ruled out. Moreover, there was no control for baseline effects in this study. Thus, it remains unclear if there were relaxation effects prior to the relaxation training (e.g. by sitting calmly on a chair). Repeated measurements during a baseline period are necessary to control for such effects. Using continuous registrations of physiological measures, a previous study by Lee and Olness (1998) showed that children and adolescents (aged 5 to 15 years) responded positively to relaxation instructions. In this study, participants were asked to think of

Relaxation in children

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quiet imagery for a period of 2 minutes. After a short interval they were instructed to imagine an exciting activity for another 2 minutes. Physiological measures employed were heart rate, peripheral temperature, and electrodermal activity. The results show signicant psychophysiological reactivity to the experimental condition. The quiet situation (in contrast to the active situation) was associated with a reduction in heart rate and an increase in peripheral temperature, indicating relaxation effects. These results suggest that neutral (non-tension producing) stories may be sufcient to induce relaxation in children. In the present study, two systematic relaxation techniques (progressive muscle relaxation and imagery-based relaxation) were compared with the presentation of neutral stories. For both systematic relaxation techniques (in contrast to the neutral stories condition), relaxation effects were expected to increase with training over a number of sessions, because children will get increasingly familiar with the principles of these relaxation techniques. The number of training sessions was limited to ve, because we assumed that ve sessions will sufce to examine any potential training effects. Thus, the focus was on an experimentally oriented comparison of the fundamental differences between the approaches and not on the adaptations of the approaches in practical use. This may also mean that short-term, immediate relaxation effects are more likely to be expected than long-term effects which may require more extensive training on relaxation techniques. The two systematic relaxation techniques chosen rely on contrasting approaches to induce relaxation. Progressive muscle relaxation targets physical reactions directly, while imagery-based relaxation approaches try to induce changes on the physiological level more indirectly by inuencing children’s cognitions (using selfinstructional or imagery-based relaxation techniques). Thus, differential effects on psychophysiological measures can be expected. More specically (and in line with ndings on short-term relaxation effects in adults), the alternating tension and relaxation of muscle groups during progressive muscle relaxation may be associated with smaller decreases in measures indicating physiological relaxation effects (Schilling & Poppen, 1984). The expectations outlined for physiological relaxation effects should also be reected in subjective ratings of psychological and physical well-being. Method Design and selection of participants The participants in the study were 64 children of the fourth and sixth grade (aged 10.0 and 12.2 years respectively) of a comprehensive school in Marburg (Germany). A comprehensive school was selected because this type of school comprises different performance levels of children and can thus be seen as being largely representative of German children of the included age groups. The proportion of girls and boys (N 5 32 each) and the proportion of fourth and sixth graders (again N 5 32 each) was identical in the sample. Children’s participation in the study required their parents’ informed consent. Participants were allocated randomly to one of three experimental conditions: progressive muscle relaxation (N 5 22), imagery-based relaxation (N 5 22) and control (N 5 20). The experimental groups were, however, stratied for gender and school grade thus leading to comparable gender and grade proportions in each experimental condition. Children participated in the study during their leisure time and were offered a nancial reward in order to prevent attrition during the training.

Equipment and measures As in the study of Lee and Olness (1996), heart rate (HR), skin temperature (ST), and skin conductance level

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(SCL) were used as physiological indicators of relaxation. HR, ST, and SCL were recorded continuously using a multi-channel polygraph. ST was monitored using an electrode xed on the forearm of the non-dominant hand. Skin conductance level (SCL) was measured in units of mS using Ag/AgCl electrodes with an isotonic cream from the hypothenar eminence of the non-dominant hand. The forearm and the non-dominant hand were placed on an armrest of a comfortable chair. HR was determined by transducing an ECG (Standard limb lead II) and counting R-peaks. Subjective experience during the experimental sessions was repeatedly assessed using a series of rating scales. Four items were related to the child’s mood (e.g. sensation of perceived calmness, subjective feeling of wellness, feeling of perceived attentiveness) and ve items to physical well-being (e.g. calmness of the heart beats, subjective body warmth, perceived dampness of the hands). The mood items were administered using 4-point rating scales on the degree of agreement (with the scale points strong agreement, agreement, disagreement, and strong disagreement), while the items on physical well-being were statements with which the children could either agree or disagree. Item ratings were added separately for mood and physical well-being to form summary scores on mood (range from 4 to 16) and physical well-being (range from 0 to 5).

Experimental protocol and procedure The training took place in a research laboratory. In all experimental conditions, the training comprised ve sessions, each lasting about 30 minutes and presented at weekly intervals. Children attended individually.All children participated in the whole sequence of ve training sessions. Each experimental session started with a 5-minute monitored rest period (baseline), during which the child was instructed to sit quietly in a comfortable chair. Then followed the relaxation training or the presentation of neutral stories. This trial lasted for approximately 8 minutes for each of the three experimental conditions (progressive muscle relaxation, imagery-based relaxation, neutral stories). The nal part of each session was a monitored 5-minute rest period (follow-up). Participants provided ratings before and after the baseline, after the relaxation training and after the follow-up period. To maximize internal validity, all training sessions were carried out in a standardized way. During training sessions, children were seated and asked to close their eyes or to look at the oor in front of them. The relaxation instructions were given from an audiotape. Although the main reason for using audiotapes was to increase standardization, it should also be noted that audiotapes are frequently used to induce relaxation in children which is shown by the large number of tapes that are available with relaxation instructions for children. Each relaxation training session began with an introductory sequence, which took about 1 minute and was identical for each session and across training conditions. This sequence was used to draw the children’s attention to the following training instructions. The experimental sessions were carried out by one of three graduate psychology students who received extensive training to prepare them for all experimental conditions. The experimental training conditions are characterized by the following features: Progressive muscle relaxation. In accordance with the principles of progressive muscle relaxation (Jacobson, 1938), children were instructed to tense and relax specic muscle groups. Because relaxation instructions were limited to 7 minutes each, the number of body parts included was smaller than in the original version of the training. The muscle groups, which were successively addressed, were hand muscles, arms, forehead, cheeks, chest, shoulders, stomach and thighs. The training instructions used in the present study were based on Bernstein and Borkovec (1973), excluding the muscles of the non-dominant forearm and hand with the attached electrodes. Imagery-based relaxation training. In each session, children were guided through a fantasy journey, imagining being a buttery going to a number of peaceful places (e.g. a meadow, a tree, or a boat). In each of the ve imagery-based relaxation sessions, the fantasy journeys started off from the laboratory, led the child to imagine going to a peaceful place and staying there for a while, before returning to the laboratory. Control condition (neutral stories). In the control condition children listened to audiotapes with neutral (nontension producing) stories. These stories were different in each session and gave the children some ideas, e.g. about the life of a tree or about natural events on a meadow. Special attention was paid to keeping these


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stories emotionally neutral to avoid the explicit or implicit induction of feelings of tension or relaxation. This control condition was designed to contrast systematic relaxation procedures to an experimental condition which does not contain elements of systematic relaxation.

Data reduction and analysis Mean levels of HR, ST, and SCL were determined over consecutive30-second epochs. The data set was further reduced to the rst nine epochs of the baseline, 14 epochs of the training session, and another nine epochs of the follow-up period. The three epochs at the beginning and at the end of the baseline period were averaged and used to indicate shifts during the baseline measurements. The means of the last three epochs of the training and the follow-up periods were used as measures of arousal at the end of each of these periods. The statistical analyses of relaxation effects exclude the rst training session and focus on the last four sessions, because it was assumed that children needed some time to adjust to the equipment used to measuring psychophysiological parameters and to the experimental procedure. The data were analysed using repeated measures analysis of variance (ANOVA).

Results Analysis of baseline changes on physiological parameters and subjective ratings The data analysis rst focused on baseline changes, because it was possible that changes during training sessions were due to baseline changes and not to changes associated with the relaxation training per se. The main questions were whether there are shifts during baseline trials and, in addition, if there are baseline differences between training conditions. Five two-way ANOVA with repeated measures were calculated to detect any signicant changes during baseline trials. Independent variables were (a) beginning vs. the end of the baseline (to indicate changes during the baseline) and (b) training conditions (in order to examine baseline differences between training conditions). Dependent variables were HR, ST, SCL, and subjective ratings on physical well-being and mood. To deal with the problem of non-sphericity the Greenhouse–Geisser adjustment to degrees of freedom was used. With the exception of mood, the results do not indicate any baseline shifts from the rst to the second baseline period (see t1 and t2 in Fig. 1 and Table 1). For mood, there is a signicant positive increase during the baseline (F(1.0, 61.0) 5 263.98, p < .01, Eta2 5 .81). There are no differences between training conditions during baseline trials. These results also suggest that there are no systematic pre-training differences between experimental conditions. Analysis of training effects on physiological parameters Because there were no signicant baseline shifts on physiological parameters, the three epochs at the beginning and the end of the baseline were combined to represent a single baseline measure. The analysis of training effects focuses on changes within and between the sessions by training condition. Three-way ANOVA with repeated measures (again applying the Greenhouse–Geisser adjustment) were calculated with (a) training conditions, (b) training sessions (excluding the rst session), and (c) the repeated measurements within the sessions (baseline epochs, the epochs at the end of the training, and the epochs taken at the end of the follow-up period) as independent variables. Dependent variables again were HR, ST, and SCL. In the case of ST, two measures of room


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Figure 1. Heart rate (a), skin conductancelevel (b), and skin temperature (c) during baseline, at the end of the training, and at the end of the follow-up period for the three training conditions. Displayed are the means of the rst and the last three epochs during the baseline (t1, t2), of the last three measurements of the training (t3), and the follow-up period (t4), averaged for training sessions 2 to 5.

Table 1. Means and standard deviations of subjective ratings on physical well-being and mood before the baseline (t1), after the baseline (t2), after the training (t3), and after the follow-up period (t4) by training condition, averaged over training sessions 2 to 5 Physical well-being Training condition NEU IMA PMR

t1 M (SD)

t2 M (SD)

t3 M (SD)

t4 M (SD)

4.54 (0.44) 4.46 (0.50) 4.50 (0.52)

4.64 (0.50) 4.47 (0.42) 4.60 (0.53)

4.59 (0.60) 4.44 (0.52) 4.63 (0.50)

4.59 (0.53) 4.58 (0.51) 4.73 (0.34)

Mood

NEU IMA PMR

t1 M (SD)

t2 M (SD)

t3 M (SD)

t4 M (SD)

12.89 (1.01) 13.27 (1.09) 13.25 (0.90)

14.35 (1.23) 14.80 (0.98) 14.84 (1.03)

14.78 (1.15) 15.50 (0.90) 15.53 (0.64)

14.78 (0.87) 14.89 (1.24) 15.25 (0.85)

Key. NEU 5 Neutral stories condition, IMA 5 imagery based relaxation, PMR 5 Progressive muscle relaxation.


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temperature (as mean initial room temperature and as difference between the room temperature at the beginning and the end of the session) were used as covariates. The results show signicant main effects for SCL for the changes within sessions (F(1.8, 112.3) 5 52.91, p < .01, Eta2 5 .46). Contrasts show a signicant change between the baseline and the end of training (F(1,61) 5 12.68, p < .01, Eta2 5 .17) as well as a signicant increase between the end of the training and the end of the follow-up period (F(1, 61) 5 82.55, p < .01, Eta2 5 .58). The signicant change for SCL between the baseline and the end of the training is due to a statistical interaction between training conditions and within session changes for SCL (F(3.7, 112.3) 5 4.01, p < .01, Eta 2 5 .12). As post hoc t tests for paired samples show (and as can be seen from Fig. 1), there is a signicant decrease in SCL for the imagery-based relaxation condition (t(21) 5 2 6.12, p < .01) and no change for the other conditions. There are no main effects for HR, but again a signicant interaction between training conditions and within session changes (F(3.5, 107.0) 5 7.50, p < .01, Eta2 5 .20). In this case, progressive muscle relaxation is associated with a signicant increase in HR from baseline to the epochs at the end of the relaxation period (t(21) 5 2.97, p < .01), while the imagerybased relaxation condition leads to a signicant decrease in HR (t(21) 5 2 4.35, p < .01). To summarize, relaxation effects are mainly related to the immediate training sessions and disappear during the follow-up period. In addition, there are no signicant changes associated with the neutral story condition. However, the trends for the neutral story condition are similar to those seen for the imagery-based relaxation condition. Although there were no signicant baseline differences between training conditions, the ANOVA was repeated with baseline parameters as covariates which, however, led to the same pattern of results and conrmed that the results are not due to baseline effects. Moreover, there were no systematic gender differences, when gender was introduced as an independent variable. Analysis of training effects on subjective ratings To analyse training effects on children’s psychological and physical well-being two threeway ANOVA with two repeated measures were calculated (with Greenhouse–Geisser adjustments). The independent variables were (a) the repeated measurements on selfreport scales within sessions, (b) training sessions (excluding the rst session), and (c) the three training conditions. Separate ANOVA were calculated for the summary scores of mood and physical well-being. Because there were no signicant differences for the ratings on physical well-being, the two ratings during the baseline were combined to represent a single baseline measure. Because of signicant changes in mood ratings between the beginning and the end of the baseline trial, ratings taken at the end of the baseline were used to represent the pre-training status. The results indicate no signicant effects for ratings of physical well-being, but for mood there is a signicant main effect for changes within sessions (F(2.0, 120.5) 5 22.10, p < .01, Eta2 5 .27). Contrasts show signicant increases in positive mood from the end of the baseline to the end of the training (F(1, 61) 5 46.84, p < .01, Eta2 5 .43) and signicant decreases from the end of the training to the end of follow-up period (F(1, 61) 5 11.35, p < .01, Eta2 5 .16). Means and standard deviations for changes within sessions are summarized in Table 1. It should be noted, however, that the

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children’s ratings are very positive in every part of a session, even before baseline. Thus, there might be ceiling effects preventing more distinct effects on mood and physical wellbeing during training periods. Discussion In summary, the results from this study indicate only short-term effects of relaxation training. A physiological pattern indicating relaxation is most clearly associated with the imagery-based relaxation approach (decreases in heart rate and skin conductance level), although skin temperature remains unchanged. A similar pattern also emerged for the neutral story condition suggesting that the induced relaxation is not specic for systematic relaxation training (although the changes associated with the neutral stories condition did not reach statistical signicance). The pattern is similar to the psychophysiological effects of self-induced quiet mental imagery in children reported by Lee and Olness (1996). In contrast, progressive muscle relaxation did not show a physiological pattern, which would be expected from a relaxation technique (i.e. increase in HR). This increase may result from the successive activation of muscle groups in this training condition which may obscure relaxation effects on the physiological level. This could mean that any relaxation effects would become apparent only after the training and not immediately during the training period. Heart rate is the only parameter showing this pattern for progressive muscle relaxation. There is indeed a signicant interaction between training conditions and the repeated measurements at the end of the training and the followup period (F(2, 61) 5 8.73, p < .01, Eta 2 5 .22). However, although there is a decrease, it does not reach values below baseline. Thus, in contrast to imagery-based relaxation, there are no clear relaxation effects for progressive muscle relaxation on psychophysiological parameters. In adults, Borkovec and Sides (1979) showed that progressive muscle relaxation will signicantly decrease physiological arousal if trainees are very experienced in this technique. We would speculate, therefore, that a programme comprising only ve training sessions may not have been long enough to produce the required level of experience. The results differ from those of the previous study by Lohaus and Klein-Heßling (2000) which showed comparable short-term effects for both the imagery-based relaxation and the sensory training condition (reduction in blood pressure and heart rate, more positive ratings for mood and physical well-being). The psychophysiological variables were recorded discontinuously before and after the training and not immediately during the training period where the differential pattern emerged in the present study. Moreover, subjective ratings of training effects may deviate from the physiological pattern observed. Particularly during progressive muscle relaxation, the periods after tensing the muscles may be experienced subjectively as relaxing, although these periods may be too short to lead to decreases in heart rate which may still be increased from the effort to tense muscles. Thus, although the physiological pattern may not show deactivation and relaxation, the subjective experience may well be a feeling of relaxation immediately after the respective muscle tension. This interpretation is supported by the lack of differences between the training conditions for the subjective ratings of mood which show improvements in positive mood during the sessions, but no differences between training conditions. However, this lack of differentiation can also be caused by ceiling effects, since the initial ratings are already so high that it may be difcult to detect differences between training conditions.


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Although there are training effects on skin conductance level and heart rate, there are neither main effects nor interactions related to skin temperature. Although the trends point in the expected direction, the effects may not be strong enough to be reected in clear vasodilative effects which would be associated with temperature increases. It should also be noted that there were unexpected increases in SCL at the end of the follow-up period. The values are signicantly above the baseline, although they had decreased during the training period. It is possible that the children may have had problems in sitting calmly in their chair for another 4-minute follow-up period and that they became restless at the end of this period which may have increased SCL. The change in the experimental procedure from training to the follow-up period may also be responsible for these changes in SCL (which are independent of the training condition and thus seem to be triggered by general situational changes). It is interesting to note that there are no systematic improvements with the increase of training sessions. This result suggests that relaxation training mainly leads to immediate effects which are conned to the training period. Repeated training over ve sessions is obviously not sufcient to produce trans-situational effects. The immediate effects (especially for imagery-based relaxation) show that children may benet from relaxation training and that relaxation instructions may induce calmness even in young children. These effects are, however, similar to those produced by the neutral stories condition, thus indicating that several approaches (and not only systematic relaxation techniques) may induce the immediate effect of feeling relaxed and calm in children. Inducing longer-lasting effects is probably much more difcult and requires more intensive training. This, however, may be a problem particularly for younger children, because of motivational difculties with using relaxation techniques systematically over longer periods. Especially in the context of primary prevention where children seldom perceive immediate effects of coping with physical or mental symptoms, it may be difcult to motivate younger children to use systematic relaxation techniques. As a consequence, the primary aim should be to get children acquainted with the immediate effects of relaxation training to induce feelings of calmness in specic situations, but not to expect long-lasting effects. Acknowledgement This study was supported by a grant of the German Science Foundation (Deutsche Forschungsgemeinschaft) to Arnold Lohaus (Az. Lo 337/10-1).

References Armstrong, F. D., Collins, F. L., Greene, P., & Panzironi, H. (1988). Effects of brief relaxation training on children’s motor functioning. Journal of Clinical Child Psychology, 17, 310–315. Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training. Champaign, IL: Research Press. Borkovec, T. D., & Sides, K. K. (1979). Critical procedure variables to the physiological effects of progressive relaxation. A review. Behavioral Research and Therapy, 17, 119–125. Creer, T. L. (1991). The application of behavioral procedures to childhood asthma: Current and future perspectives. Patient Education and Counseling, 17, 9–22. Jacobson, E. (1938). Progressive relaxation. Chicago, IL: University of Chicago Press. King, J. N., Ollendick, T. H., Murphy, G. C., & Molloy, G. N. (1998). Utility of relaxation training with

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children in school settings: A plea for realistic goal setting and evaluation. British Journal of Educational Psychology, 68, 53–66. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lee, L. H., & Olness, M. D. (1996). Effects of self-induced mental imagery on autonomic reactivity in children. Journal of Developmental and Behavioral Pediatrics, 17, 323–327. Lohaus, A., Klein-Heßling, J., & Shebar, S. (1997). Stress management for elementary school children: A comparative evaluation of different approaches. European Review of Applied Psychology, 47, 157–161. Lohaus, A. & Klein-Heßling, J. (2000). Coping in childhood: A comparative evaluation of different relaxation techniques. Anxiety, Stress, and Coping, 13, 187–211. Plantania-Solazzo, A., Field, T. M., Blank, J., & Seligman, F. (1992). Relaxation therapy reduces anxiety in child and adolescent psychiatric patients. Acta Paedopsychiatrica, 55, 115–120. Sartory, G., Mueller, B., Metsch, J., & Pothmann, R. (1998). A comparison of psychological and pharmacological training of pediatric migraine. Behavioral Research and Therapy, 36, 1155–1170. Schilling, D. J., & Poppen, R. (1984). Behavioral relaxation training and assessment. Journal of Behavior Therapy and Experimental Psychiatry, 14, 99–107. Spirito, A., & Stark, L. (1991). Common problems and coping strategies reported in childhood and early adolescence. Journal of Youth and Adolescence, 20, 531–544. Received 20 July 1999; revised version received 14 January 2000