Adrianna Amari

Interdisciplinary Behavioral Rehabilitation of Pediatric Pain-Associated Disability: Retrospective Review of an Inpatient Treatment Protocol

OBJECTIVEnA biopsychosocial model was used to treat pain-associated disability in children and adolescents. We assessed the clinical outcomes of children and adolescents (8-21 years of age) with pain-associated disability who were treated in an interdisciplinary inpatient rehabilitation program which included physical, occupational, and recreational therapy, medicine, nursing, pediatric psychology, neuropsychology, psychiatry, social work, and education. Psychological treatment emphasized cognitive-behavioral intervention for pain and anxiety management, and behavioral shaping to increase functioning.nnnMETHODSnWe conducted a retrospective chart review of 41 consecutive patients. School attendance, sleep, and medication usage were assessed at admission and discharge; functional disability and physical mobility were assessed at admission, discharge, and 3-month follow-up.nnnRESULTSnAs a group, significant improvements were observed in school status, sleep, functional ability, physical mobility, and medication usage.nnnCONCLUSIONnFindings support the efficacy of an inpatient interdisciplinary behavioral rehabilitation approach to the treatment of pain-associated disability in pediatric patients.

Social Interaction Patterns of Children and Adolescents With and Without Oral Clefts During a Videotaped Analogue Social Encounter

Objective To examine the social interaction patterns of children with and without oral clefts. Design Participants were videotaped while interacting with a peer confederate. Oral cleft and control groups were compared on social behavior and several self- and parent-report measures. Participants Thirty-four 8- to 15-year-olds with oral clefts, matched for sex, age, and socioeconomic status with 34 noncleft controls. Main Outcome Measures Data were obtained on social behaviors coded from videotapes and on child and parent ratings of social acceptance/competence and facial appearance. Results Statistically significant differences were found between groups: children with clefts made fewer choices and more often failed to respond to peer questions; children with clefts and their parents reported greater dissatisfaction with the childs facial appearance; and parents of children with clefts rated them as less socially competent. Significant within-group associations were also found. Parent perception of child social competence and child self-perception of social acceptance were positively correlated for both groups. Children with clefts who felt more socially accepted more often looked a peer in the face. Controls who felt more socially accepted chose an activity less often during the social encounter. Conclusions Differing patterns of overt social behavior as well as parent and self-perception can be measured between children with and without oral clefts. Such results may be helpful in developing interventions to enhance social skills and parent/child adjustment.

Behavioral Training for Increasing Preschool Children's Adherence With Positive Airway Pressure: A Preliminary Study

Behavioral training was implemented to increase adherence with positive airway pressure (PAP) in 4 preschool children. The training employed distraction, counterconditioning, graduated exposure, differential reinforcement, and escape extinction. A non-concurrent multiple baseline experimental design was used to demonstrate program effects. Initially, the children displayed distress and escape–avoidance behavior when PAP was attempted. With training, all 4 children tolerated PAP while sleeping for age appropriate durations. For the 3 children with home follow-up data, the parents maintained benefits. The results are discussed in relation to behavior principles, child health, and common barriers to PAP adherence.

Behavior management for children and adolescents with acquired brain injury

Behavioral problems such as disinhibition, irritability, restlessness, distractibility, and aggression are common after acquired brain injury (ABI). The persistence and severity of these problems impair the brain-injured individuals reintegration into family, school, and community life. Since the early 1980s, behavior analysis and therapy have been used to address the behavioral sequelae of ABI. These interventions are based on principles of learning and behavior that have been robustly successful when applied across a broad range of other clinical populations. Most of the research on behavioral treatment after ABI has involved clinical case studies or studies employing single-subject experimental designs across a series of cases. The literature supports the effectiveness of these interventions across ages, injury severities, and stages of recovery after ABI. Recommended guidelines for behavior management include: direct behavioral observations, systematic assessment of environmental and within-patient variables associated with aberrant behavior, antecedent management to minimize the probability of aberrant behavior, provision of functionally equivalent alternative means of controlling the environment, and differential reinforcement to shape positive behavior and coping strategies while not inadvertently shaping emergent, disruptive sequelae. This package of interventions requires direction by a highly skilled behavioral psychologist or therapist who systematically monitors target behavior to evaluate progress and guide treatment decisions. A coordinated multisite effort is needed to design intervention protocols that can be studied prospectively in randomized controlled trials. However, there will continue to be an important role for single subject experimental design for studying the results of individualized interventions and obtaining pilot data to guide subsequent randomized controlled trails.

Self-Concept and Satisfaction With Physical Appearance in Youth With and Without Oral Clefts

This study investigated relationships between child/parent dissatisfaction with child facial appearance and the self-concept/social competence of 8- to 15-year-old children with (N = 34) and without (N = 34) oral clefts. Children in both groups had normative psychosocial adjustment, but also reported moderate dissatisfaction with facial appearance. Cleft group parents were more likely to agree with their childs dissatisfaction. When cleft group parents were more dissatisfied with child facial appearance, their children reported better quality of life. Results suggest that parents of children with clefts reporting greater dissatisfaction may respond in positive ways that enhance quality of life.

Social acceptance and facial behavior in children with oral clefts.

Objective To examine and compare social acceptance, social behavior, and facial movements of children with and without oral clefts in an experimental setting. Design Two groups of children (with and without oral clefts) were videotaped in a structured social interaction with a peer confederate, when listening to emotional stories, and when told to pose specific facial expressions. Participants Twenty-four children and adolescents ages 7 to 161/2 years with oral clefts were group matched for gender, grade, and socioeconomic status with 25 noncleft controls. Main Outcome Measures Specific social and facial behaviors coded from videotapes; Harter Self-Perception Profile, Social Acceptance subscale. Results Significant between-group differences were obtained. Children in the cleft group more often displayed “Tongue Out,” “Eye Contact,” “Mimicry,” and “Initiates Conversation.” For the cleft group, “Gaze Avoidance” was significantly negatively correlated with social acceptance scores. The groups were comparable in their ability to pose and spontaneously express facial emotion. Conclusions When comparing children with and without oral clefts in an experimental setting, with a relatively small sample size, behavior analysis identified some significant differences in patterns of social behavior but not in the ability to express facial emotion. Results suggest that many children with oral clefts may have relatively typical social development. However, for those who do have social competence deficits, systematic behavioral observation of atypical social responses may help individualize social skills interventions.

Assessment of facial emotion encoding and decoding skills in children with and without oral clefts

PURPOSEnInvestigated the facial emotion decoding and encoding skills and perceived social acceptance in children with and without oral clefts.nnnPATIENTSn8-15 year-old children with surgically repaired facial clefts (n=19) and non-cleft controls (n=19).nnnMETHODSnThe children viewed photographs of facial emotions expressed by other children and identified the emotion in each photograph. They were videotaped while listening to a series of brief vignettes designed to evoke facial emotions and while posing prototypic facial expressions. They also completed a measure of their perceived social acceptance. Judges, blind to experimental group and targeted emotion, viewed systematically sampled video images, then recorded their subjective judgement of the emotion expressed in each. Trained coders also scored selected images using objective measures of the degree to which specific facial movements associated with emotion-specified expressions were present.nnnRESULTSnAnalysis of variance procedures detected significantly different patterns of facial responses between the oral cleft and control groups, and within group. Pearson correlation analyses found significant relationships between specific facial movements and perceived social acceptance.nnnCONCLUSIONnSystematic assessment of facial expression in children with oral clefts can identify unique differences in their encoding of facial emotion and may lead to behavioural interventions to improve social functioning by training facial expression skills.

Children and Adolescents with Chronic Pain and Functional Disability: Use of a Behavioral Rehabilitation Approach

Children and adolescents who present with various chronic pain experiences and associated functional disability often share common behavioral and clinical features. Caring for these patients is challenging to health care providers and expensive for the medical community. Given the complexity of interrelated medical, psychological, and environmental variables potentially involved, a biopsychosocial conceptualization of assessment and treatment is helpful. Recent research has been able to demonstrate the effectiveness of treating children and adolescents suffering from chronic pain within an interdisciplinary rehabilitation environment. An interdisciplinary inpatient behavioral rehabilitation approach is described in detail along with how it compares to related day-hospital pain programs and outpatient services.

Response to the Commentary: A Worldwide Call for Multimodal Inpatient Treatment for Children and Adolescents Suffering from Chronic Pain and Pain-related Disability

The commentary by Hechler, Dobe, & Zernikow (2009) that discusses our retrospective review of an inpa- tient protocol for pain-associated disability (Maynard, Amari, Wieczorek, Christensen, & Slifer, 2009) highlights a number of important points for consideration regarding the worldwide need and standards for multimodal inpa- tient treatment of children and adolescents with chron- ic pain and pain-related disability. In their commentary and recent work reporting the results of a similar multimodal inpatient protocol, Hechler, Blankenburg, Dobe, Kosfelder, Hubner, & Zernikowet, (2009) have cogently set forth important standards for future clinical trials of multidisciplinary inpatient treatment for chronic pain and functional disability in chil- dren and adolescents. We acknowledged the considerable limitations of a retrospective study in Maynard et al. (2009). We fully acknowledge the need to interpret the results of our study with caution, given its limitations. We have discussed the need for prospective, randomized controlled clinical trials involving multiple centers, and using both a standard protocol and standardized out- come measures. The prospective studies by Dobe, Damschen, Reiffer-Wiesel, Sauer, & Zernikow (2006) and Hechler, Blankenburg, et al. (2009) should be encouraged, and we commend them for their fine work. Our objective in publishing our limited retrospect- ive clinical results was to focus more attention in the field on the relatively untapped potential for multidiscip- linary inpatient treatment within a rehabilitation setting to interrupt the downward spiral of pain, avoidance behavior and increasing disability in children and adoles- cents. Although we conducted a retrospective study, the clinical outcomes seen using our protocol have been encouraging. This along with the increasing demand for a brief inpatient alternative for patients who are not responsive to more typical outpatient pain clinic services seemed worth presenting to our colleagues in pediatric psychology. As noted in the commentary, we recognize that the sample size of 41 is less than optimal. Again, based upon the available data that we had at our institute, we felt that it was meaningful to present this information despite this relative weakness. We agree with Hechler, Dobe, et al. (2009) that future research studies should obtain larger sample sizes and more complete follow-up data at standard intervals post-discharge. A longer follow-up period beyond our 3-month assessment is critical to evaluating mainten- ance and generalization of treatment effects. The need for reporting pain intensity was also discussed in the commentary. Clearly, these data are important and should be included in future studies. Our clinical objective has been to de-emphasize pain ratings relative to functional outcomes with our patients and families. We agree that this does not obviate the need for obtaining pain intensity data. We recommend that the number of times per day that intensity ratings are obtained should be made standard and time based rather than con- tingent on observed distress. Patients subjective pain ex- perience should be acknowledged with both empathy and objectivity, but a contingent association between distress behavior and social attention or termination of therapy demands should be carefully avoided. Subjective pain in- tensity ratings are obtained on our inpatient unit by the nursing staff at standard times. However, we did not have the research resources to conduct validity and reliability analyses on these pain intensity ratings from our clinical database. Certainly, it is important to obtain these data systematically in any prospective research study, preferably using the core outcome measures recommended by Hechler, Dobe, et al. (2009) and the PedIMMPACT