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Pain in children: psychosocial
Abstracts
103
(978) Plotting the trajectory of pain treatment in children: An integrated qualitative-quantitative approach
(980) Issues in measuring children‘s preferred style of coping with pain
M. Meldrum, B. Bursch, M. Nutkiewicz, L. Zeltzer, A. Ogiamien, J. Heritage, M. Jacob; University of California-Los Angeles, Los Angeles, CA Recurrent and intractable pain disorders, including recurrent abdominal pain, headache, limb pain and chest pain, affect 10-20% of children, but are often inadequately treated. The Pediatric Pain Program at UCLA employs a biopsychosocial model based on the assumption that the child‘s tendency to fixate on pain and pain-related distress is reinforced by feelings of inability to cope with family, school and social problems, and that the physical distress in turn reinforces his/her feelings of inadequacy, low self-esteem, anxiety, and depression. The treatment program emphasizes the teaching of coping skills and enhancement of self-efficacy, in conjunction with medical and complementary therapies to alleviate the pain. Although interdisciplinary programs such as this have been reported to be effective for many patients, evaluation using a standard RCT or other quantitative methodology is problematic. Also, although qualitative and interview methodologies are often used in clinical research, the data collected may be considered too “soft” or anecdotal to be used as evidence of therapeutic efficacy. We are employing an innovative approach to evaluating the pain program using a combination of three methodologies: pre and post-treatment aggregate statistical analysis, based on validated scale instruments completed by the child and a parent; conversational analysis of physician-patient encounters; and grounded theory analysis of extended semi-structured pre and post-treatment oral history interviews conducted with the children. Through the integration of our findings from each methodology, we hope to plot a trajectory of growth in self-efficacy and normal functioning during the course of treatment and to isolate specific factors that may contribute to successful outcomes. We will present a possible treatment trajectory based on the analysis of several cases and demonstrate how the qualitative material will be used to test and support quantitative findings from the statistical analysis.
A. McCarthy, C. Kleiber, K. Hanrahan; University of Iowa, Iowa City, IA Some children cope with medical procedures by closely watching while others prefer to look away. Matching specific distress reducing cognitive behavioral interventions with a child‘s preferred coping style may increase the effectiveness of the interventions (Fanurik et al., 1993; Miller et al. 1995). However determining coping style is difficult because the few existing validated child self report coping instruments are cumbersome to use. Sometimes parent report is accepted as a proxy for children‘s preferred coping style. This poster presents preliminary comparisons between child and parent report of child coping style, and between two self report measures of preferred coping style for children. Subjects are children (4 to 10 years old) scheduled for an IV insertion in the outpatient setting, and their parents. Children and parents independently answer one question: “If you (your child) fell down and scraped a knee and your mom or dad (you) were going to wash it off and put a band-aid on it, what would you rather do, watch or look away?” Then children complete the Child Behavior Style Scale or CBSS (Miller et al., 1995), a validated measure of monitoring and blunting coping styles. Results are presented for the first 100 child-parent dyads from a large study evaluating predictors of child distress during IV insertion. There are significant differences between child and parent responses to the coping style question, with just 67% overall agreement among childparent dyads and a kappa coefficient of .23. Children who said they would watch had a significantly higher mean score on the CBSS monitoring subscale. Parents may not be accurate judges of their children‘s preferred coping style. A simple screening question about watching or looking away from a painful event may be a useful alternative to more complicated screening tools for coping style.
(979) Who functions despite the pain? Building a model of family and parent influences on functional abilities in children with RAP and migraine
F10 - Social and Cultural Variables
D. Logan, N. Taylor, L. Scharff; Children‘s Hospital Boston, Boston, MA The objective was to determine family characteristics that influence children‘s ability to function with pain. We hypothesized that parental psychological distress (anxiety, depression, somatization, global distress) and family traits previously reported in the chronic pain literature (i.e., family conflict, chaos, enmeshment) would influence children‘s functional ability beyond what is explained by pain intensity. To date, participants include 79 children ages 7-17 years (M ⫽ 12.3 years) with diagnoses of migraine (n ⫽ 52) or recurrent abdominal pain (n ⫽ 27) recruited from clinic settings. Thus far 52 girls and 27 boys and their parents have completed assessment measures. Children completed pain diaries over four weeks, rating pain intensity on a 0-4 scale four times daily. They also completed the Functional Disability Inventory. Both parents completed self-report measures of psychological functioning, and mothers completed the Family Environment Scale. Partial correlations controlling for pain ratings indicate that impaired functioning associates most closely with greater family conflict (r ⫽ 0.42, p⬍.001), chaos/ disorganization (r ⫽ .38, p⬍.01), less independence(r ⫽ -.26, p⬍.05), and maternal psychological distress (r ⫽ .26, p⬍.05). Using hierarchical multivariate linear regression, we assessed the influence of family environment (support, conflict, disorganization and enmeshment) and parental functioning (mothers’ and fathers’ global psychological distress) on children‘s functional impairment. Accounting for the influence of pain intensity [adj r2⫽ 0.33, F change (1, 42) ⫽ 22.9, p⬍.001], family environment and parental distress jointly predict children‘s ability to function with pain [r2 change ⫽ .26, F change (6, 36) ⫽ 3.9, p⬍.01]. Family characteristics appear to be important determinants of the extent of “painrelated disability syndrome” and can help identify children who are likely to suffer higher levels of impaired functioning regardless of pain intensity. A potential model of family influences on functional ability is proposed, with implications for family-based intervention strategies.
(981) Persistent Pain Stigma Questionnaire (PPSQ): Preliminary validation of a measure to assess perception of negative attitudes towards people with pain P. Reed, D. Zelman, J. Rosenberg; CA School of Professional Psychology - Alliant International University, Alameda, CA Research has documented negative public attitudes towards those with certain chronic medical conditions (stigma), which can influence patient mood, interpersonal relationships and health behaviors. To explore this phenomenon for persistent pain, we created the Persistent Pain Stigma Questionnaire (PPSQ), a 28-item Likert-type inventory evaluating patients’ perceptions of negative attitudes held by their family, physicians and the general public and across hypothesized dimensions of pain-related stigma (e.g. beliefs that people with pain misuse pain medication, somaticize, malinger, or deserve blame). A representative item is “Doctors think that people with chronic pain exaggerate their pain.” Participants (N⫽178) with moderate-severe persistent back pain or osteoarthritis (pain severity ⬎4 on a 0-10 scale) completed the PPSQ and measures of mood and function (BDI, HADS, SF-36). Internal consistency, factor structure, convergent and discriminant validity and individual item responses were evaluated. High alpha reliability ( ⬎.85) was found for the three perceived stigma (PS) sources (general public, physician and family). Principal components analysis with rotation detected three interpretable factors (eigenvalues1.0, 54.5% of variance) roughly consistent with those sources. Patient ratings of PS differed between sources, from highest to lowest: general public, physicians, family (p⬍.001). PS was modestly associated with depression measures (r‘s of .25-.30, p⬍.001), higher among patients on “permanent disability” (p⬍.01), and lower among African Americans than Caucasians (p⫽.001). Frequently endorsed items included “People believe that chronic pain is used as an excuse to get pain medication” (71.6%) and “Doctors think that people with chronic pain want more pain medication than is necessary” (68.8%). This study provides preliminary psychometric data for the PPSQ. Many people with persistent pain expect to encounter negative attitudes among physicians and the general public. Further research is needed to explore the impact of perceived stigma on patients’ acceptance of and adherence to prescribed pain medications. Supported by Purdue Pharma LP.
103
(978) Plotting the trajectory of pain treatment in children: An integrated qualitative-quantitative approach
(980) Issues in measuring children‘s preferred style of coping with pain
M. Meldrum, B. Bursch, M. Nutkiewicz, L. Zeltzer, A. Ogiamien, J. Heritage, M. Jacob; University of California-Los Angeles, Los Angeles, CA Recurrent and intractable pain disorders, including recurrent abdominal pain, headache, limb pain and chest pain, affect 10-20% of children, but are often inadequately treated. The Pediatric Pain Program at UCLA employs a biopsychosocial model based on the assumption that the child‘s tendency to fixate on pain and pain-related distress is reinforced by feelings of inability to cope with family, school and social problems, and that the physical distress in turn reinforces his/her feelings of inadequacy, low self-esteem, anxiety, and depression. The treatment program emphasizes the teaching of coping skills and enhancement of self-efficacy, in conjunction with medical and complementary therapies to alleviate the pain. Although interdisciplinary programs such as this have been reported to be effective for many patients, evaluation using a standard RCT or other quantitative methodology is problematic. Also, although qualitative and interview methodologies are often used in clinical research, the data collected may be considered too “soft” or anecdotal to be used as evidence of therapeutic efficacy. We are employing an innovative approach to evaluating the pain program using a combination of three methodologies: pre and post-treatment aggregate statistical analysis, based on validated scale instruments completed by the child and a parent; conversational analysis of physician-patient encounters; and grounded theory analysis of extended semi-structured pre and post-treatment oral history interviews conducted with the children. Through the integration of our findings from each methodology, we hope to plot a trajectory of growth in self-efficacy and normal functioning during the course of treatment and to isolate specific factors that may contribute to successful outcomes. We will present a possible treatment trajectory based on the analysis of several cases and demonstrate how the qualitative material will be used to test and support quantitative findings from the statistical analysis.
A. McCarthy, C. Kleiber, K. Hanrahan; University of Iowa, Iowa City, IA Some children cope with medical procedures by closely watching while others prefer to look away. Matching specific distress reducing cognitive behavioral interventions with a child‘s preferred coping style may increase the effectiveness of the interventions (Fanurik et al., 1993; Miller et al. 1995). However determining coping style is difficult because the few existing validated child self report coping instruments are cumbersome to use. Sometimes parent report is accepted as a proxy for children‘s preferred coping style. This poster presents preliminary comparisons between child and parent report of child coping style, and between two self report measures of preferred coping style for children. Subjects are children (4 to 10 years old) scheduled for an IV insertion in the outpatient setting, and their parents. Children and parents independently answer one question: “If you (your child) fell down and scraped a knee and your mom or dad (you) were going to wash it off and put a band-aid on it, what would you rather do, watch or look away?” Then children complete the Child Behavior Style Scale or CBSS (Miller et al., 1995), a validated measure of monitoring and blunting coping styles. Results are presented for the first 100 child-parent dyads from a large study evaluating predictors of child distress during IV insertion. There are significant differences between child and parent responses to the coping style question, with just 67% overall agreement among childparent dyads and a kappa coefficient of .23. Children who said they would watch had a significantly higher mean score on the CBSS monitoring subscale. Parents may not be accurate judges of their children‘s preferred coping style. A simple screening question about watching or looking away from a painful event may be a useful alternative to more complicated screening tools for coping style.
(979) Who functions despite the pain? Building a model of family and parent influences on functional abilities in children with RAP and migraine
F10 - Social and Cultural Variables
D. Logan, N. Taylor, L. Scharff; Children‘s Hospital Boston, Boston, MA The objective was to determine family characteristics that influence children‘s ability to function with pain. We hypothesized that parental psychological distress (anxiety, depression, somatization, global distress) and family traits previously reported in the chronic pain literature (i.e., family conflict, chaos, enmeshment) would influence children‘s functional ability beyond what is explained by pain intensity. To date, participants include 79 children ages 7-17 years (M ⫽ 12.3 years) with diagnoses of migraine (n ⫽ 52) or recurrent abdominal pain (n ⫽ 27) recruited from clinic settings. Thus far 52 girls and 27 boys and their parents have completed assessment measures. Children completed pain diaries over four weeks, rating pain intensity on a 0-4 scale four times daily. They also completed the Functional Disability Inventory. Both parents completed self-report measures of psychological functioning, and mothers completed the Family Environment Scale. Partial correlations controlling for pain ratings indicate that impaired functioning associates most closely with greater family conflict (r ⫽ 0.42, p⬍.001), chaos/ disorganization (r ⫽ .38, p⬍.01), less independence(r ⫽ -.26, p⬍.05), and maternal psychological distress (r ⫽ .26, p⬍.05). Using hierarchical multivariate linear regression, we assessed the influence of family environment (support, conflict, disorganization and enmeshment) and parental functioning (mothers’ and fathers’ global psychological distress) on children‘s functional impairment. Accounting for the influence of pain intensity [adj r2⫽ 0.33, F change (1, 42) ⫽ 22.9, p⬍.001], family environment and parental distress jointly predict children‘s ability to function with pain [r2 change ⫽ .26, F change (6, 36) ⫽ 3.9, p⬍.01]. Family characteristics appear to be important determinants of the extent of “painrelated disability syndrome” and can help identify children who are likely to suffer higher levels of impaired functioning regardless of pain intensity. A potential model of family influences on functional ability is proposed, with implications for family-based intervention strategies.
(981) Persistent Pain Stigma Questionnaire (PPSQ): Preliminary validation of a measure to assess perception of negative attitudes towards people with pain P. Reed, D. Zelman, J. Rosenberg; CA School of Professional Psychology - Alliant International University, Alameda, CA Research has documented negative public attitudes towards those with certain chronic medical conditions (stigma), which can influence patient mood, interpersonal relationships and health behaviors. To explore this phenomenon for persistent pain, we created the Persistent Pain Stigma Questionnaire (PPSQ), a 28-item Likert-type inventory evaluating patients’ perceptions of negative attitudes held by their family, physicians and the general public and across hypothesized dimensions of pain-related stigma (e.g. beliefs that people with pain misuse pain medication, somaticize, malinger, or deserve blame). A representative item is “Doctors think that people with chronic pain exaggerate their pain.” Participants (N⫽178) with moderate-severe persistent back pain or osteoarthritis (pain severity ⬎4 on a 0-10 scale) completed the PPSQ and measures of mood and function (BDI, HADS, SF-36). Internal consistency, factor structure, convergent and discriminant validity and individual item responses were evaluated. High alpha reliability ( ⬎.85) was found for the three perceived stigma (PS) sources (general public, physician and family). Principal components analysis with rotation detected three interpretable factors (eigenvalues1.0, 54.5% of variance) roughly consistent with those sources. Patient ratings of PS differed between sources, from highest to lowest: general public, physicians, family (p⬍.001). PS was modestly associated with depression measures (r‘s of .25-.30, p⬍.001), higher among patients on “permanent disability” (p⬍.01), and lower among African Americans than Caucasians (p⫽.001). Frequently endorsed items included “People believe that chronic pain is used as an excuse to get pain medication” (71.6%) and “Doctors think that people with chronic pain want more pain medication than is necessary” (68.8%). This study provides preliminary psychometric data for the PPSQ. Many people with persistent pain expect to encounter negative attitudes among physicians and the general public. Further research is needed to explore the impact of perceived stigma on patients’ acceptance of and adherence to prescribed pain medications. Supported by Purdue Pharma LP.