Publications by authors named "Lauren C Heathcote"

49 Publications

Prevalence and predictors of cancer-related worry and associations with health behaviors in adult survivors of childhood cancer.

Cancer 2021 Apr 12. Epub 2021 Apr 12.

Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: Cancer-related worry (CRW) is common among cancer survivors; however, little is known about factors associated with CRW or its impact on health behaviors in adult survivors of childhood cancer.

Methods: Survivors in the St. Jude Lifetime Cohort Study (n = 3211; 51% male; mean age, 31.2 years [SD, 8.4 years]; mean time after diagnosis, 22.8 years [SD, 8.3 years]) underwent medical evaluations and completed ratings of CRW, psychological symptoms, and health behaviors. Multivariable modified Poisson regression models examined associations between CRW and treatment exposures, chronic health conditions, psychological symptoms, and health behaviors.

Results: Sixty-four percent of survivors (95% confidence interval [CI], 62.6-65.9) reported worry about subsequent malignancy, 45% (95% CI, 43.5-46.9) reported worry about physical problems related to cancer, and 33% (95% CI, 31.2-34.4) reported worry about relapse. Multiple psychological symptoms, treatment exposures, and chronic conditions significantly increased the risk of CRW. Survivors reporting CRW were at increased risk for substance use, inadequate physical activity, and increased health care utilization after adjustments for chronic conditions. For example, with adjustments for chronic conditions, those who endorsed CRW were more likely to have ≥5 cancer-related physician visits, ≥5 physician visits related to cancer, and ≥5 calls to a physician's office in the previous 2 years in comparison with survivors who were not worried. CRW was also associated with an increased risk of current tobacco use, past marijuana use, and current marijuana use.

Conclusions: A substantial proportion of adult survivors of childhood cancer reported CRW associated with increased health care utilization. CRW may serve as an intervention target to promote well-being and adaptive health behaviors.
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http://dx.doi.org/10.1002/cncr.33563DOI Listing
April 2021

Using Mediation Analysis to Understand How Treatments for Paediatric Pain Work: A Systematic Review and Recommendations for Future Research.

Children (Basel) 2021 Feb 16;8(2). Epub 2021 Feb 16.

Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK.

Clinicians have an increasing number of evidence-based interventions to treat pain in youth. Mediation analysis offers a way of investigating how interventions work, by examining the extent to which an intermediate variable, or mediator, explains the effect of an intervention. This systematic review examined studies that used mediation analysis to investigate mechanisms of interventions on pain-relevant outcomes for youth (3-18 years) with acute or chronic pain, and provides recommendations for future mediation research in this field. We searched five electronic databases for clinical trials or observational longitudinal studies that included a comparison group and conducted mediation analyses of interventions on youth and assessed pain outcomes. We found six studies ( = 635), which included a total of 53 mediation models examining how interventions affect pain-relevant outcomes for youth. Five studies were secondary analyses of randomized controlled trials of psychological interventions for chronic pain; one was a longitudinal observational study of morphine for acute pain. The pain conditions studied were irritable bowel syndrome, functional abdominal pain, juvenile fibromyalgia, mixed chronic pain, and post-operative pain. Fourteen putative mediators were tested, of which three partially mediated treatment effect; seven did not significantly mediate treatment effect and four had mixed results. Methodological and reporting limitations were common. There are substantial gaps in the field with respect to investigating, and therefore understanding, how paediatric interventions work.
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http://dx.doi.org/10.3390/children8020147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919827PMC
February 2021

Longitudinal Narrative Analysis of Parent Experiences During Graded Exposure Treatment for Children With Chronic Pain.

Clin J Pain 2021 Apr;37(4):301-309

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.

Objectives: Parents have a vital influence over their child's chronic pain treatment and management. Graded exposure in vivo treatment (GET) is emerging as a promising intervention for youth with chronic pain. Yet, little is known about how parents perceive GET and its impact on their child's pain condition. This study aimed to characterize caregivers' experiences over the course of their child's GET using longitudinal coding and thematic analysis of parent narratives.

Materials And Methods: Parent narratives of 15 youth who participated in GET for pediatric chronic pain (GET Living) were elicited from an unstructured dialogue at the start of each treatment session held between the parent(s) and pain psychologist. Narratives were coded for affect and content, and trends were examined in these codes across sessions. Common themes in parent narratives were developed through inductive thematic analysis.

Results: Parents showed an increase in positive affect, treatment confidence, and optimism over the course of treatment. Narratives also expressed more benefit-finding/growth and less anxiety and protectiveness across GET sessions, with more parents having a resolved orientation towards their child's pain by the final session. Five common themes were generated: Self-Awareness, Understanding of Their Child's Perspective, Perceived Treatment Benefit, Internalization of Treatment Principles, and Hopeful Concern for the Future.

Discussion: Analysis of parent narratives provides a rich and unique method for understanding a parent's journey during their child's chronic pain treatment. Clinical application of our findings can be used to guide future developments of targeted topics and interventions in the context of parenting a child with chronic pain.
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http://dx.doi.org/10.1097/AJP.0000000000000921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953686PMC
April 2021

Worry about somatic symptoms as a sign of cancer recurrence: prevalence and associations with fear of recurrence and quality of life in survivors of childhood cancer.

Psychooncology 2021 Feb 5. Epub 2021 Feb 5.

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA.

Objective: Somatic symptoms (e.g., pain, fatigue) are common after childhood cancer and are associated with greater fear of cancer recurrence and poorer health-related quality of life (HRQoL). Qualitative studies indicate that survivors of childhood cancer (SCCs) worry about somatic symptoms as indicating cancer recurrence, which could in part explain associations between symptoms and poorer psychosocial outcomes. However, the prevalence, characteristics, and impact of symptom worry has not been quantitatively studied.

Methods: SCCs (N = 111; 52% female; Mage at study = 17.67 years, range = 8-25 years; Mage at diagnosis = 6.70 years) across a variety of diagnoses were recruited from a pediatric cancer center in Canada and completed self-report measures of symptom worry, symptom frequency, general anxiety, fear of cancer recurrence, and HRQoL.

Results: A majority (62%) of SCCs worried about at least one symptom as a sign of recurrence. Pain was the most worrisome symptom, but SCCs also reported worrying about symptoms that are rarely associated with cancer recurrence such as hunger, dizziness, and feeling cold. Symptom worry was more strongly associated with fear of cancer recurrence than the mere frequency of those symptoms, and this relationship held while controlling for treatment factors and general anxiety. Symptom worry and frequency each explained unique variance in HRQoL.

Conclusions: Worry about somatic symptoms as a sign of cancer recurrence is common and may be impactful after childhood cancer. Excessive worry about somatic symptoms could be an important target to reduce fear of recurrence and increase HRQoL in SCCs.
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http://dx.doi.org/10.1002/pon.5647DOI Listing
February 2021

Mother-child communication about possible cancer recurrence during childhood cancer survivorship.

Psychooncology 2021 Apr 3;30(4):536-545. Epub 2020 Dec 3.

Department of Psychology & Human Development, Vanderbilt University, Nashville, Tennessee, USA.

Objective: Providing opportunities to communicate about possible cancer recurrence may be adaptive for youth in remission, yet parents may experience difficulty guiding discussions related to fears of cancer recurrence (FCR). This study aimed to characterize mother-child discussions about potential cancer recurrence during post-treatment survivorship and to determine predictors of maternal communication.

Methods: Families (N = 67) were recruited after the child's initial cancer diagnosis (age 5-17 years) and mothers self-reported their distress (post-traumatic stress symptoms; PTSS). During survivorship 3-5 years later, mothers were video-recorded discussing cancer with their children. Presence and length of discussion about potential cancer recurrence, triggers for FCR, expressed affect, and conversational reciprocity were examined. Hierarchical regressions were used to assess maternal PTSS near the time of cancer diagnosis and child age as predictors of maternal communication.

Results: Three-quarters of dyads spontaneously discussed risk for or fears about cancer recurrence; mothers initiated the topic more frequently than their children. Dyads discussed internal (bodily symptoms) and external (medical, social) triggers of FCR. Higher maternal PTSS at diagnosis predicted significantly lower levels of maternal positive affect (β = -0.36, p = 0.02) and higher levels of maternal negative affect (β = 0.30, p = 0.04) during discussion of recurrence 3-5 years later. Older child age significantly predicted higher levels of maternal negative affect (β = 0.35, p = 0.02). Higher maternal PTSS at diagnosis predicted shorter discussions about recurrence for younger children (β = 0.27, p = 0.02).

Conclusions: Understanding predictors and characteristics of mother-child discussions about recurrence can guide family-based FCR interventions, particularly those promoting communication as a supportive tool. Both maternal PTSS and child age are important to consider when developing these interventions.
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http://dx.doi.org/10.1002/pon.5600DOI Listing
April 2021

Pain in long-term survivors of childhood cancer: A systematic review of the current state of knowledge and a call to action from the Children's Oncology Group.

Cancer 2020 Jan 28;127(1):35-44. Epub 2020 Oct 28.

Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, Tennessee.

Survivors of childhood cancer may be at risk of experiencing pain, and a systematic review would advance our understanding of pain in this population. The objective of this study was to describe: 1) the prevalence of pain in survivors of childhood cancer, 2) methods of pain measurement, 3) associations between pain and biopsychosocial factors, and 4) recommendations for future research. Data sources for the study were articles published from January 1990 to August 2019 identified in the PubMed, PsycINFO, EMBASE, and Web of Science data bases. Eligible studies included: 1) original research, 2) quantitative assessments of pain, 3) articles published in English, 4) cancers diagnosed between birth and age 21 years, 5) survivors at 5 years from diagnosis and/or at 2 years after therapy completion, and 6) a sample size >20. Seventy-three articles were included in the final review. Risk of bias was considered using the Cochrane risk of bias tool. The quality of evidence was evaluated according to Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria. Common measures of pain were items created by the authors for the purpose of the study (45.2%) or health-related quality-of-life/health status questionnaires (42.5%). Pain was present in from 4.3% to 75% of survivors across studies. Three studies investigated chronic pain according the definition in the International Classification of Diseases. The findings indicated that survivors of childhood cancer are at higher risk of experiencing pain compared with controls. Fatigue was consistently associated with pain, females reported more pain than males, and other factors related to pain will require stronger evidence. Theoretically grounded, multidimensional measurements of pain are absent from the literature.
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http://dx.doi.org/10.1002/cncr.33289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875461PMC
January 2020

Symptom appraisal in uncertainty: a theory-driven thematic analysis with survivors of childhood cancer.

Psychol Health 2020 Oct 19:1-18. Epub 2020 Oct 19.

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Objective: Somatic symptoms capture attention, demand interpretation, and promote health behaviors. Symptom appraisal is particularly impactful within uncertain health contexts such as cancer survivorship. Yet, little is known about how individuals make sense of somatic symptoms within uncertain health contexts, nor how this process guides health behaviors.

Design: 25 adolescent and young adult survivors of childhood cancer completed semi-structured interviews regarding how they appraise and respond to changing somatic sensations within the uncertain context of survivorship.

Main Outcome Measures: Interviews were transcribed verbatim and subjected to a hybrid deductive-inductive thematic analysis, guided by the Cancer Threat Interpretation model.

Results: We constructed three themes. S (theme 1) captured that participants described commonly interpreting and worrying about everyday sensations as indicating cancer recurrence or new illness. (theme 2) captured participants' felt need to employ cognitive and behavioral strategies to determine whether somatic sensations indicated a credible health threat. These two themes are qualified by the final theme, (theme 3), which captured participants' recognition that post-cancer symptoms are wily and influenced by psychological factors such as anxiety.

Conclusions: These data highlight that making sense of everday somatic sensations can be particularly challenging following an experience of cancer. There is a need for novel symptom management approaches that target how somatic sensations are appraised and responded to as signals of bodily threat.
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http://dx.doi.org/10.1080/08870446.2020.1836180DOI Listing
October 2020

Fear of cancer recurrence in childhood cancer survivors: A developmental perspective from infancy to young adulthood.

Psychooncology 2020 11 26;29(11):1959-1967. Epub 2020 Oct 26.

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA.

Aims: Fear of cancer recurrence (FCR) is among the most prevalent and distressing concerns reported by cancer survivors. While younger age is the most consistent predictor of elevated FCR, research to date has focused almost exclusively on adult cancer survivors. This is despite the fact that children with cancer are more likely to survive compared to adults, and will become regular, lifelong users of the medical system to mitigate the effects of toxic treatment. The early experience of cancer yields unique challenges and circumstances that may impact children's capacity for and experience of FCR across the developmental trajectory. The aim of this paper is to present a developmental perspective of FCR from infancy to young adulthood.

Methods: Drawing on the developmental science literature and recent theoretical advancements in FCR, we outline cognitive and social factors that may influence children's capacity for and experience of FCR across the developmental trajectory.

Results: First, distinct developmental groups that fall under the classification of "childhood cancer survivor," and that all require attention, are summarized. Using the structure of these groupings, we centrally provide a developmental perspective of FCR that offers a useful starting point for research in pediatric populations. Key research gaps, including the need for validated assessment tools to measure FCR in child and adolescent survivors, are highlighted.

Conclusions: Consideration of the unique context of childhood is needed to guide the identification of childhood cancer survivors at risk for FCR as well as the development of effective FCR interventions for this population.
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http://dx.doi.org/10.1002/pon.5576DOI Listing
November 2020

Which passengers are on your bus? A taxonomy of the barriers adolescents with chronic pain face in achieving functional recovery.

Eur J Pain 2021 Feb 8;25(2):348-358. Epub 2020 Nov 8.

Division of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, UK.

Background: Despite evidence that intensive interdisciplinary pain treatment (IIPT) is effective in facilitating functional recovery in adolescents with chronic pain, engagement with IIPT is suboptimal among adolescents. A key aspect of IIPT is to support functional recovery via (re)engagement with age-appropriate daily activities. The aim of this study was to gain a comprehensive insight into adolescents' perceptions of the barriers they need to overcome to engage with age-appropriate activities in order to achieve functional recovery.

Methods: Forty-one adolescents who were starting an IIPT programme completed the 'passenger-on-the-bus metaphor', an exercise in which they identify and describe their perceived barriers (i.e. 'passengers' on their bus) that prevent them from engaging with age-appropriate activities. The responses were analysed using inductive thematic analyses to generate a taxonomy of perceived barriers to functional recovery.

Results: We generated a taxonomy of seven different barriers that participants described facing on their road to functional recovery: physical constraints, being 'fed up', low self-confidence and self-esteem, perfectionism, avoidance of engagement with pain, feelings (such as sadness, anger, guilt, anxiety) and social barriers (received from a range of sources such as parents, friends, school and wider society).

Conclusion: The findings reveal a variety of barriers that were perceived to hinder functional recovery through reduced engagement with age-appropriate activities and thereby hamper progress within IIPT. The Passenger on the bus metaphor can be used to identify similar barriers faced by adolescents in an individualized treatment approach, thereby making it possible for clinicians to target their IIPT more precisely.
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http://dx.doi.org/10.1002/ejp.1673DOI Listing
February 2021

Something Else Going On? Diagnostic Uncertainty in Children with Chronic Pain and Their Parents.

Children (Basel) 2020 Oct 4;7(10). Epub 2020 Oct 4.

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA.

Diagnostic uncertainty, the perceived lack of an accurate explanation of the patient's health problem, remains relatively unstudied in children. This study examined the prevalence, familial concordance, and correlates of diagnostic uncertainty in children and their parents presenting to a multidisciplinary pain clinic in the United States. One hundred and twenty-six parents and 91 of their children ( = 13.93 years, range = 8-18 years) completed a brief three-item measure of diagnostic uncertainty, as well as measures of pain-related distress and functioning. Forty-eight percent of children and 37% of parents believed something else was going on with the child's pain that doctors had not found out about yet. Across the three items, 66%-77% of children and their parents agreed in their endorsement of diagnostic uncertainty. Parents who believed that something else was going on with their child's pain had children with higher avoidance of pain-related activities ( = 5.601, = 0.020) and lower pain willingness ( = 4.782, = 0.032). Neither parent nor child diagnostic uncertainty was significantly related to the child's pain-related functioning. Diagnostic uncertainty, particularly in parents, is relevant in the experience of pediatric chronic pain and warrants further investigation as both a risk factor and therapeutic target.
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http://dx.doi.org/10.3390/children7100165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599582PMC
October 2020

The time course of attentional biases in pain: a meta-analysis of eye-tracking studies.

Pain 2021 Mar;162(3):687-701

Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium.

Abstract: Previous meta-analyses investigating attentional biases towards pain have used reaction time measures. Eye-tracking methods have been adopted to more directly and reliably assess biases, but this literature has not been synthesized in relation to pain. This meta-analysis aimed to investigate the nature and time course of attentional biases to pain-related stimuli in participants of all ages with and without chronic pain using eye-tracking studies and determine the role of task parameters and theoretically relevant moderators. After screening, 24 studies were included with a total sample of 1425 participants. Between-group analyses revealed no significant overall group differences for people with and without chronic pain on biases to pain-related stimuli. Results indicated significant attentional biases towards pain-related words or pictures across both groups on probability of first fixation (k = 21, g = 0.43, 95% confidence interval [CI] 0.15-0.71, P = 0.002), how long participants looked at each picture in the first 500 ms (500-ms epoch dwell: k = 5, g = 0.69, 95% CI 0.034-1.35, P = 0.039), and how long participants looked at each picture overall (total dwell time: k = 25, g = 0.44, 95% CI 0.15-0.72, P = 0.003). Follow-up analyses revealed significant attentional biases on probability of first fixation, latency to first fixation and dwell time for facial stimuli, and number of fixations for sensory word stimuli. Moderator analyses revealed substantial influence of task parameters and some influence of threat status and study quality. Findings support biases in both vigilance and attentional maintenance for pain-related stimuli but suggest attentional biases towards pain are ubiquitous and not related to pain status.
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http://dx.doi.org/10.1097/j.pain.0000000000002083DOI Listing
March 2021

Do qualitative interviews cause distress in adolescents and young adults asked to discuss fears of cancer recurrence?

Psychooncology 2021 Jan 15;30(1):123-126. Epub 2020 Sep 15.

Department of Medical Oncology, Stanford University School of Medicine, Stanford, California, USA.

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http://dx.doi.org/10.1002/pon.5544DOI Listing
January 2021

mHealth for pediatric chronic pain: state of the art and future directions.

Expert Rev Neurother 2020 11 23;20(11):1177-1187. Epub 2020 Sep 23.

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine , Palo Alto, CA, USA.

Introduction: Chronic pain conditions are common among children and engender cascading effects across social, emotional, and behavioral domains for the child and family. Mobile health (mHealth) describes the practice of delivering healthcare via mobile devices and may be an ideal solution to increase access and reach of evidence-based behavioral health interventions.

Areas Covered: The aim of this narrative review is to present a state-of-the-art overview of evidence-based mHealth efforts within the field of pediatric chronic pain and consider new and promising directions for study. Given the nascent nature of the field, published mHealth interventions in all stages of development are discussed. Literature was identified through a non-systematic search in PubMed and Google Scholar, and a review of reference lists of papers that were identified as particularly relevant or foundational (within and outside of the chronic pain literature).

Expert Opinion: mHealth is a promising interventional modality with early evidence suggesting it is primed to enhance behavioral health delivery and patient outcomes. There are many exciting future directions to be explored including drawing inspiration from digital health technology to generate new ways of thinking about the optimal treatment of pediatric chronic pain.
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http://dx.doi.org/10.1080/14737175.2020.1819792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657989PMC
November 2020

Cancer Survivorship-Considering Mindsets.

JAMA Oncol 2020 09;6(9):1468-1469

Department of Psychology, Stanford University, Palo Alto, California.

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http://dx.doi.org/10.1001/jamaoncol.2020.2482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644142PMC
September 2020

Attentional biases in pediatric chronic pain: an eye-tracking study assessing the nature of the bias and its relation to attentional control.

Pain 2020 10;161(10):2263-2273

Department of Psychology, University of Calgary, Calgary, AB, Canada.

Attentional biases are posited to play a key role in the development and maintenance of chronic pain in adults and youth. However, research to date has yielded mixed findings, and few studies have examined attentional biases in pediatric samples. This study used eye-gaze tracking to examine attentional biases to pain-related stimuli in a clinical sample of youth with chronic pain and pain-free controls. The moderating role of attentional control was also examined. Youth with chronic pain (n = 102) and pain-free controls (n = 53) viewed images of children depicting varying levels of pain expressiveness paired with neutral faces while their eye gaze was recorded. Attentional control was assessed using both a questionnaire and a behavioural task. Both groups were more likely to first fixate on high pain faces but showed no such orienting bias for moderate or low pain faces. Youth with chronic pain fixated longer on all pain faces than neutral faces, whereas youth in the control group exhibited a total fixation bias only for high and moderate pain faces. Attentional control did not moderate attentional biases between or within groups. The results lend support to theoretical models positing the presence of attentional biases in youth with chronic pain. Further research is required to clarify the nature of attentional biases and their relationship to clinical outcomes.
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http://dx.doi.org/10.1097/j.pain.0000000000001916DOI Listing
October 2020

Stuck on pain? Assessing children's vigilance and awareness of pain sensations.

Eur J Pain 2020 08 28;24(7):1339-1347. Epub 2020 May 28.

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Background: Attending towards pain is proposed as a key mechanism influencing the experience and chronification of pain. Persistent attention towards pain is proposed to drive poor outcomes in both adults and children with chronic pain. However, there are no validated self-report measures of pain-related attention for children.

Methods: The goals of this study were to adapt the Pain Vigilance and Awareness Questionnaire (PVAQ) for use in a child sample, to preliminary examine its psychometric properties, and to assess its utility over and above a measure of general attentional capacities. We adapted the language of the PVAQ to be more easily understood by children as young as 8 years. In a sample of 160 children (8-18 years) with chronic pain, we examined the factor structure, internal consistency and criterion validity of the PVAQ-C.

Results: The PVAQ-C demonstrated excellent internal consistency (α = 0.92) and moderate-to-strong criterion validity. A one-factor structure best fit the data. Children who reported greater attention to pain also reported greater pain catastrophizing, fear of pain, avoidance of activities and poorer physical functioning. Pain-related attention remained a significant predictor of functioning while controlling for demographics, catastrophizing and fear-avoidance. Pain-related attention also significantly predicted child outcomes independent of the child's general attention control capacities, indicating added value of a pain-specific measure of attention.

Conclusions: The PVAQ-C shows strong indices of internal reliability and criterion validity, and indicates unique predictive utility. It will be important to study the role of pain-related attention in youth within developmental and functional-motivational frameworks.

Significance: Pain-related attention is proposed as a key factor influencing fear-avoidance outcomes in both adults and youth with chronic pain, yet no self-report measures of pain-related attention have been validated for children. This paper presents a child version of the Pain Vigilance and Awareness Questionnaire (PVAQ-C), which indicates strong internal consistency, criterion validity and unique predictive validity, and provides evidence to support the Fear-Avoidance Model in youth with chronic pain.
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http://dx.doi.org/10.1002/ejp.1581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387216PMC
August 2020

Parent Responses to Their Child's Pain: Systematic Review and Meta-Analysis of Measures.

J Pediatr Psychol 2020 04;45(3):281-298

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine.

Objective: Parent responses can have a major impact on their child's pain. The purpose of this systematic review is to (a) identify and describe measures assessing pain-related cognitive, affective, and behavioral responses in parents of children with chronic pain and (b) meta-analyze reported correlations between parent constructs and child outcomes (i.e., pain intensity, functional disability, and school functioning). Prospero protocol registration ID: CRD42019125496.

Methods: We conducted a systematic search of studies including a measure of parent/caregiver responses to their child's chronic pain. Study characteristics and correlations between parent measures and child outcomes were extracted. Data were summarized and meta-analyzed.

Results: Seventy-nine met inclusion criteria using 18 different measures of cognitive/affective (n = 3), behavioral (n = 5), and multidimensional responses (n = 10). Measures were used a median of three times (range 1-48), predominantly completed by mothers (88%), and primarily in mixed pain samples. Psychometrics of measures were generally adequate. Meta-analyses were based on 42 papers across five measures. Results showed that each of the cognitive, affective, and behavioral parent constructs we examined was significantly associated with pain-related functional disability. A small number of measures assessing parent cognitions and affective functioning were associated with higher child pain intensity; however, the majority were not.

Conclusion: Findings demonstrate that there is a wealth of measures available, with adequate reliability overall but a lack of psychometrics on temporal stability. Synthesizing data across studies revealed small effects between parent responses and child functioning, and even smaller and/or absent effects on child pain intensity.
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http://dx.doi.org/10.1093/jpepsy/jsaa005DOI Listing
April 2020

Parent physical and mental health contributions to interpersonal fear avoidance processes in pediatric chronic pain.

Pain 2020 06;161(6):1202-1211

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States.

Theoretical models and evidence increasingly identify chronic pain as a family issue. To date, much of this work has focused on risk conferred by parental chronic pain status despite evidence suggesting parent mental illness and non-pain-related chronic illness may also contribute to poorer chronic pain outcomes in children. This study is the first to test interpersonal fear avoidance processes as possible mechanisms through which parent health (mental and physical) influences pediatric chronic pain functioning. We used structural equation models to test such an integrative model using cross-sectional data from a large clinical registry of 448 dyads of patients aged between 8 and 18 years (M = 14.57 years; SD = 2.38; 327 females) with mixed chronic pain and their parents (403 mothers). As expected, poorer parent global health was indirectly related to greater child pain interference through higher parent pain catastrophizing, and then through greater parent protective behaviors and child pain catastrophizing. The model demonstrated excellent fit to the data (χ[5] = 5.04, ns; χ/df = 1.01; comparative fit index = 1.00, root mean square error of approximation = 0.004 [90% confidence interval = 0.000 to 0.066]). Exploratory multiple-group comparison structural equation model revealed moderation of specific model paths based on child age group (8- to 12-year-olds vs 13- to 18-year-olds) and parent pain status (present vs absent). This study integrates family models of pain with the interpersonal fear avoidance model to extend our mechanistic understanding of parental physical and mental health contributors to pediatric chronic pain.
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http://dx.doi.org/10.1097/j.pain.0000000000001820DOI Listing
June 2020

Brain signatures of threat-safety discrimination in adolescent chronic pain.

Pain 2020 03;161(3):630-640

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States.

Approximately 1.7 million youth suffer from debilitating chronic pain in the US alone, conferring risk of continued pain in adulthood. Aberrations in threat-safety (T-S) discrimination are proposed to contribute to pain chronicity in adults and youth by interacting with pain-related distress. Yet, few studies have examined the neural circuitry underlying T-S discrimination in patients with chronic pain or how T-S discrimination relates to pain-related distress. In this study, 91 adolescents (10-24 years; 78 females) including 30 chronic pain patients with high pain-related distress, 29 chronic pain patients with low pain-related distress, and 32 healthy peers without chronic pain completed a developmentally appropriate T-S learning paradigm. We measured self-reported fear, psychophysiology (skin conductance response), and functional magnetic resonance imaging responses (N = 72 after functional magnetic resonance imaging exclusions). After controlling for age and anxiety symptoms, patients with high pain-related distress showed altered self-reported fear and frontolimbic activity in response to learned threat and safety cues compared with both patients with low pain-related distress and healthy controls. Specifically, adolescent patients with high pain-related distress reported elevated fear and showed elevated limbic (hippocampus and amygdala) activation in response to a learned threat cue (CS+). In addition, they showed decreased frontal (vmPFC) activation and aberrant frontolimbic connectivity in response to a learned safety cue (CS-). Patients with low pain-related distress and healthy controls appeared strikingly similar across brain and behavior. These findings indicate that altered T-S discrimination, mediated by frontolimbic activation and connectivity, may be one mechanism maintaining pain chronicity in adolescents with high levels of pain-related distress.
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http://dx.doi.org/10.1097/j.pain.0000000000001753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7018610PMC
March 2020

Rapid identification and clinical indices of fear-avoidance in youth with chronic pain.

Pain 2020 03;161(3):565-573

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States.

Pain-related fear and avoidance are increasingly demonstrated to play an important role in adult and childhood chronic pain. The Fear of Pain Questionnaire for Children (FOPQC) is a 24-item measure of pain-related fear-avoidance in youth that has demonstrated good indices of reliability and validity, treatment responsiveness, and associations with brain circuitry alterations. This study describes the development and psychometric examination of the FOPQC-SF, a short form of the original measure. We selected 10 items for the short form that best represented the content and 2-factor (fear and avoidance) structure of the original measure from a cohort of 613 youth (Mage = 14.7 years) with chronic pain. Next, confirmatory factor analyses from a second sample of 526 youth (Mage = 14.7 years) with chronic pain who completed the FOPQC-SF supported the original 2-factor model but indicated that one item should be moved to the avoidance subscale. The FOPQC-SF demonstrates strong internal consistency and moderate-to-strong construct and criterion validity. The 3-month test-retest reliability estimates (N = 94) were strong, and there was preliminary evidence of responsivity to change. To aid integration into intervention trials and clinical practice, we provide clinical reference points and a criterion to assess reliable change. The short form could be used for rapid identification of pain-related fear and avoidance in youth during clinic evaluations, and is optimized for clinical registries.
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http://dx.doi.org/10.1097/j.pain.0000000000001742DOI Listing
March 2020

Assessing the content specificity of interpretation biases in community adolescents with persistent and interfering pain.

Pain 2020 02;161(2):319-327

Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.

The tendency to select threatening over benign interpretations of ambiguous bodily sensations and cues characterises young people with chronic pain. However, previous studies disagree over whether these biases extend to nonbodily harm situations such as social evaluation. Understanding the content of these biases is crucial to the development of pain management strategies seeking to modify such biases. Two hundred forty-three young people aged 16 to 19 years completed an expanded version of the Adolescent Interpretation of Bodily Threat task. Using a factor-analytic approach, we removed items that did not consistently associate with bodily harm or social evaluation. Next, we examined whether the variance underlying negative and benign interpretations of bodily harm and social evaluation situations were best represented as a common factor (ie, one-factor model), 2 distinct factors (ie, 2-factor model), or one common and 2 distinct factors (ie, 2-factor bifactor model) in all adolescents. We then compared youth with and without persistent and impairing pain on factor scores derived from the best-fitting model. Although negative interpretations of bodily harm and social evaluation situations emerged as distinct factors, benign interpretations across situations were best captured by a common factor and 2 situation-specific factors (ie, bifactor model). Group comparisons showed that young people with moderate-to-high pain interference were more likely to endorse negative interpretations across all situations, and less likely to manifest a general benign interpretational style, than youth without interfering pain, although some of these group differences were explained by co-occurring anxiety and depressive symptoms. Replication of these findings is needed.
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http://dx.doi.org/10.1097/j.pain.0000000000001723DOI Listing
February 2020

The interaction between stress and chronic pain through the lens of threat learning.

Neurosci Biobehav Rev 2019 12 14;107:641-655. Epub 2019 Oct 14.

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States.

Stress and pain are interleaved at multiple levels - interacting and influencing each other. Both are modulated by psychosocial factors including fears, beliefs, and goals, and are served by overlapping neural substrates. One major contributing factor in the development and maintenance of chronic pain is threat learning, with pain as an emotionally-salient threat - or stressor. Here, we argue that threat learning is a central mechanism and contributor, mediating the relationship between stress and chronic pain. We review the state of the art on (mal)adaptive learning in chronic pain, and on effects of stress and particularly cortisol on learning. We then provide a theoretical integration of how stress may affect chronic pain through its effect on threat learning. Prolonged stress, as may be experienced by patients with chronic pain, and its resulting changes in key brain networks modulating stress responses and threat learning, may further exacerbate these impairing effects on threat learning. We provide testable hypotheses and suggestions for how this integration may guide future research and clinical approaches in chronic pain.
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http://dx.doi.org/10.1016/j.neubiorev.2019.10.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914269PMC
December 2019

Pharmacological interventions for chronic pain in children: an overview of systematic reviews.

Pain 2019 08;160(8):1698-1707

German Paediatric Pain Centre, Children's and Adolescent's Hospital, Datteln, Germany.

We know little about the safety or efficacy of pharmacological medicines for children and adolescents with chronic pain, despite their common use. Our aim was to conduct an overview review of systematic reviews of pharmacological interventions that purport to reduce pain in children with chronic noncancer pain (CNCP) or chronic cancer-related pain (CCRP). We searched the Cochrane Database of Systematic Reviews, Medline, EMBASE, and DARE for systematic reviews from inception to March 2018. We conducted reference and citation searches of included reviews. We included children (0-18 years of age) with CNCP or CCRP. We extracted the review characteristics and primary outcomes of ≥30% participant-reported pain relief and patient global impression of change. We sifted 704 abstracts and included 23 systematic reviews investigating children with CNCP or CCRP. Seven of those 23 reviews included 6 trials that involved children with CNCP. There were no randomised controlled trials in reviews relating to reducing pain in CCRP. We were unable to combine data in a meta-analysis. Overall, the quality of evidence was very low, and we have very little confidence in the effect estimates. The state of evidence of randomized controlled trials in this field is poor; we have no evidence from randomised controlled trials for pharmacological interventions in children with cancer-related pain, yet cannot deny individual children access to potential pain relief. Prospero ID: CRD42018086900.
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http://dx.doi.org/10.1097/j.pain.0000000000001609DOI Listing
August 2019

Commentary: From Symptoms to Sensations: Moving Toward a Normal Psychology of Somatic Experiences in Youth.

J Pediatr Psychol 2019 Aug;44(7):859-861

Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine.

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http://dx.doi.org/10.1093/jpepsy/jsz028DOI Listing
August 2019

When "a headache is not just a headache": A qualitative examination of parent and child experiences of pain after childhood cancer.

Psychooncology 2019 09 16;28(9):1901-1909. Epub 2019 Jul 16.

Patient Partner, Toronto, Ontario, Canada.

Objective: Today, more than 80% of children diagnosed with cancer are expected to survive. Despite the high prevalence of pain associated with the diagnosis and treatment of childhood cancer, there is a limited understanding of how having cancer shapes children's experience and meaning of pain after treatment has ended. This study addresses this gap by exploring childhood cancer survivors' (CCS') experiences of pain from their perspective and the perspective of their parents.

Methods: Twenty semi-structured interviews were completed with CCS (50% female; mean age = 13.20 y, range = 8-17 y) and their parents (90% mothers). Data were analyzed using interpretive phenomenological analysis.

Results: Analyses revealed three superordinate themes present in the data: (a) pain is a changed experience after childhood cancer; (b) new or ambiguous pains may be interpreted by CCS and parents as a threat of disease recurrence, late effects, or a secondary cancer; and (c) pain interpretation occurs within the broader context of how CCS and parents appraise their cancer experience. Parents generally appraised their child's cancer and pain as more threatening and were influential in guiding their child's interpretations.

Conclusions: The cancer experience played an important role in shaping CCS' and their parents' experience and interpretation of pain in survivorship. This study provides novel data to inform the development and refinement of new and existing conceptual models of pain and symptom perception after cancer. The results also point to key areas for future investigation and clinical intervention to address the issue of pain in cancer survivorship.
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http://dx.doi.org/10.1002/pon.5170DOI Listing
September 2019

Pain Education for Adolescents and Young Adults Living Beyond Cancer: An Interdisciplinary Meeting Report.

J Adolesc Young Adult Oncol 2019 10 31;8(5):529-533. Epub 2019 May 31.

School of Health Sciences/University of South Australia Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia.

Pain is an understudied and undertreated consequence of cancer survival. Pain education is now a recommended treatment approach for persistent non-cancer pain, yet it has not been well applied to the context of adolescent and young adult (AYA) cancer survival. In March 2018, an interdisciplinary meeting was held in Adelaide, South Australia to set a research agenda for pain education in AYA cancer survivors. We identified that AYAs with persistent pain and those with heightened pain-related fear have the potential to benefit from pain education. We identified a number of unique challenges of engaging AYA survivors in pain education, and point towards future research directions.
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http://dx.doi.org/10.1089/jayao.2019.0047DOI Listing
October 2019

"My Surgical Success": Effect of a Digital Behavioral Pain Medicine Intervention on Time to Opioid Cessation After Breast Cancer Surgery-A Pilot Randomized Controlled Clinical Trial.

Pain Med 2019 11;20(11):2228-2237

Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA.

Objective: This study aims to assess the feasibility of digital perioperative behavioral pain medicine intervention in breast cancer surgery and evaluate its impact on pain catastrophizing, pain, and opioid cessation after surgery.

Design And Setting: A randomized controlled clinical trial was conducted at Stanford University (Palo Alto, CA, USA) comparing a digital behavioral pain medicine intervention ("My Surgical Success" [MSS]) with digital general health education (HE).

Participants: A convenience sample of 127 participants were randomized to treatment group. The analytic sample was 68 patients (N = 36 MSS, N = 32 HE).

Main Outcomes: The primary outcome was feasibility and acceptability of a digital behavioral pain medicine intervention (80% threshold for acceptability items). Secondary outcomes were pain catastrophizing, past seven-day average pain intensity, and time to opioid cessation after surgery for patients who initiated opioid use.

Results: The attrition rate for MSS intervention (44%) was notably higher than for HE controls (18%), but it was lower than typical attrition rates for e-health interventions (60-80%). Despite greater attrition for MSS, feasibility was demonstrated for the 56% of MSS engagers, and the 80% threshold for acceptability was met. We observed a floor effect for baseline pain catastrophizing, and no significant group differences were found for postsurgical pain catastrophizing or pain intensity. MSS was associated with 86% increased odds of opioid cessation within the 12-week study period relative to HE controls (hazard ratio = 1.86, 95% confidence interval = 1.12-3.10, P = 0.016).

Conclusions: Fifty-six percent of patients assigned to MSS engaged with the online platform and reported high satisfaction. MSS was associated with significantly accelerated opioid cessation after surgery (five-day difference) with no difference in pain report relative to controls. Perioperative digital behavioral pain medicine may be a low-cost, accessible adjunct that could promote opioid cessation after breast cancer surgery.
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http://dx.doi.org/10.1093/pm/pnz094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830264PMC
November 2019

Pain neuroscience education on YouTube.

PeerJ 2019 22;7:e6603. Epub 2019 Mar 22.

Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States of America.

Objectives: The Internet in general, and YouTube in particular, is now one of the most popular sources of health-related information. Pain neuroscience education has become a primary tool for managing persistent pain, based in part on the discovery that information about pain can change pain. Our objective was to examine the availability, characteristics, and content of YouTube videos that address the neuroscience of pain.

Methods: We conducted a systematic review of videos on YouTube using the search terms "pain education", "what is pain", and "pain brain" in January 2018. Videos were included if they were in English, were under 10 minutes long, and included information on the neuroscience of pain. Videos were coded for (i) descriptive characteristics (e.g., number of views, duration on YouTube), (ii) source and style, (iii) whether or not they addressed seven pre-determined target concepts of pain neuroscience education (e.g., 'Pain is not an accurate marker of tissue state'), and (iv) how engaging they were.

Results: We found 106 unique videos that met the inclusion criteria. The videos ranged from having four views to over five million views ( = 1,163 views), with the three most highly viewed videos accounting for 75% of the total views. Animated videos were much more highly viewed than non-animated videos. Only a small number of videos had been posted by a clearly-identifiable reputable source such as an academic or medical institution (10%), although a number of videos were posted by healthcare professionals and professional medical societies. For a small number of videos (7%), the source was unclear. We found 17 videos that addressed at least one target concept of pain neuroscience science education, only nine of which were considered to be at least somewhat engaging. The target concept 'Pain is a brain output' was considered to be well addressed by the most videos ( = 11), followed by 'Pain is a protector' ( = 10). We found only one video that adequately addressed all seven target concepts of pain neuroscience education.

Discussion: YouTube contains a variety of videos that practitioners, patients, and families may view to access pain neuroscience education information. A small portion of these videos addressed one or more target concepts of pain neuroscience education in an engaging manner. It is yet to be determined to what extent patients are able to learn information from these videos, to what extent the videos promote behavior change, and thus to what extent the videos may be useful for clinical practice.
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http://dx.doi.org/10.7717/peerj.6603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432903PMC
March 2019

Somatic Symptoms in Pediatric Patients With Chronic Pain: Proposed Clinical Reference Points for the Children's Somatic Symptoms Inventory (Formerly the Children's Somatization Inventory).

J Pain 2019 08 13;20(8):932-940. Epub 2019 Feb 13.

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California.

Among youth with chronic pain, elevated somatic symptoms across multiple body systems have been associated with greater emotional distress and functional disability and could represent poor adaptation to pain. The Children's Somatic Symptoms Inventory (formerly the Children's Somatization Inventory) is commonly used to assess somatic symptoms in children. However, no studies have evaluated the clinical usefulness of the measure in the assessment of pediatric patients with chronic pain. This study evaluated the factor structure and clinical relevance of the 24-item Children's Somatic Symptoms Inventory (CSSI-24) in youth (n = 1,150) with mixed chronic pain complaints presenting to a tertiary pain clinic. The CSSI-24 total scores were equal or superior to factor scores as indicators of patients' clinical characteristics (functional disability, pain catastrophizing, fear of pain, and anxiety and depressive symptoms) and parental catastrophizing and protective responses. Tertile-derived clinical reference points for the CSSI-24 total score (<18, low; 19-31, moderate; ≥ 32, high) significantly differed on measures of clinical characteristics and parent factors. Controlling for age, sex, pain intensity, and primary pain complaint, the high somatic symptoms group exhibited significantly greater health care use compared with the moderate and low groups. The assessment of somatic symptoms in pediatric patients with chronic pain may provide useful information regarding patients' psychosocial risk and tendency to access health services. Perspective: Clinical reference points based on the CSSI-24 total scores meaningfully differentiated youth with chronic pain on measures of emotional distress, functioning, parent catastrophizing and protective responses, and health care use. Assessing somatic symptoms could provide useful information regarding a pediatric patient's psychosocial risk, tendency to access health services, and need for enhanced care coordination.
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http://dx.doi.org/10.1016/j.jpain.2019.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689439PMC
August 2019

Digitally enabled patient-reported outcome measures in cancer care - Authors' reply.

Lancet Oncol 2019 01;20(1):e3

Department of Philosophy and Department of Psychology, Yale University, New Haven, CT, USA.

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http://dx.doi.org/10.1016/S1470-2045(18)30910-0DOI Listing
January 2019