show that distraction by television had a greater analgesic effect than active distraction performed by the mothers. This is shown by both the children's self-reported scores and the mothers' scores. Mason et al, who published a study in The Journal of Clinical Psychology in Medical Settings, suggested that while both mothers and television are effective distraction techniques, the mothers may have been less effective because the children's fear and distress could have affected their ability to interact with their mothers. Influence of caregivers In the Journal of Holistic Nursing, Cavendar et al performed a study investigating the effect of parents as active distraction to the child. Children in the experimental group received standard care, but the parents were given instruction in how to distract the child. Also, they were given a choice between three distraction items. The control group received standard care, and mothers were present in the room but were not coached on distraction techniques nor given distraction items. The researchers concluded that "fear was rated as significantly lower" in the experimental group, though there was "no statistical difference between the two groups with regard to pain and distress." The way parents act and react in situations where their child is undergoing venipuncture can have an effect on children and their fear of needles. In The Journal of Family Practice, James G. Hamilton hypothesized that "needle phobia is learned as well as inherited." He observed that "negative experiences associated with immunization, laboratory work, dental visits, and other medical procedures can condition children … toward becoming fearful of needles." Other factors, such as physical and verbal restraint during children's medical procedures, can influence children to fear needles and associated medical situations. An article published in Nursing Forum by Ives et al outlined several helpful and unhelpful caregiver behaviors during venipuncture. Unhelpful behaviors included overly reassuring children, overly empathizing with children, apologizing, and criticizing children. It was also noted that giving the child control of the procedure from the beginning or asking the child to "indicate readiness to receive the needle" increased distress in the children. Other unhelpful responses included "inadequate or overly forceful restraint by the parent; shaming, threatening, yelling, slapping, lying; or, alternately, pitying, placating, bribing, and helpless parent behaviors." The researchers identified a need to provide instruction to parents on what not to say to their child. Nurses identified lack of explanation to the child as a major