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Behavioral counterconditioning was conducted during simulated medical routines to supplement medical management of five children's distress during invasive procedures (bone marrow aspiration, lumbar puncture, tracheostomy care, venipuncture, and finger pricks). Preferred activities were paired in vivo with medical stimuli, and differential positive reinforcement was provided contingent on engagement with the preferred activities and on compliance with adult instructions, first during simulations and later during actual procedures. Data on cooperation, escape/avoidance, and negative vocalizations were evaluated using both single-subject experimental methods and a baseline-treatment group statistical comparison. Results support the benefits of this approach as an adjunctive intervention to decrease behavioral distress in some children requiring repeated invasive procedures. Discussion emphasizes the potential for training medical personnel to implement these techniques preventively, for decreasing or discontinuing sedation for some children treated under local anesthesia, and for preparing children with developmental disabilities for invasive procedures. J Dev Behav Pediatr 16:133–141, 1995. Index terms: invasive procedures, behavior therapy.