Amanda L. Stone

Interacting influences of gender and chronic pain status on parasympathetically mediated heart rate variability in adolescents and young adults

Abstract Considerable research links chronic pain to autonomic nervous system (ANS) dysfunction, specifically low heart rate variability (HRV) mediated by reduced parasympathetic activity. However, little is known about factors that influence ANS function in chronic pain. The ANS is the primary pathway for brain–gut communication, making it of particular interest in gastrointestinal disorders, such as irritable bowel syndrome, characterized by functional abdominal pain (FAP). We evaluated the relation of sex, pain severity, and psychological stress to ANS function in adolescents/young adults from a database of pediatric FAP and control participants enrolled 8 years earlier in a prospective study of pain. At follow-up in adolescence/young adulthood (Mean age = 19.46, SD = 3.48), we classified participants as Pain-Remit (n = 130), Pain-Persist (n = 96), and pain-free controls (n = 123). We recorded electrocardiogram data at rest and during laboratory stressors. Results demonstrated significantly lower HRV in Pain-Persist females compared with Pain-Remit females, female controls, and all males regardless of pain category. Spectral analysis of electrocardiogram showed that Pain-Persist females had reduced power in the high frequency domain of cardiac activity, ie, reduced parasympathetic “braking” of sympathetic activity, both at rest and during stress. Pain-Remit females exhibited levels of autonomic imbalance intermediate between those of females with persistent FAP and all other participants. Parasympathetically mediated low HRV in young women with persistent FAP may reflect a peripheral mechanism (eg, gut dysfunction) or a central nervous system mechanism (eg, pain amplification or poor emotion self-regulation) involving prolonged sympathetic activation.

Nausea in Children With Functional Abdominal Pain Predicts Poor Health Outcomes in Young Adulthood

Background & Aims Nausea is common among children with functional abdominal pain (FAP). We evaluated the relation of nausea to short‐ and long‐term morbidity in pediatric patients with FAP. Methods We performed a prospective study of 871 children with FAP (age, 8–17 y) seen in a pediatric gastroenterology practice; follow‐up data were collected from 392 of the patients at 8.7 ± 3.3 years later. Participants were defined as having significant nausea if they reported nausea “a lot” or “a whole lot” within the past 2 weeks. Validated questionnaires assessed abdominal pain, gastrointestinal and somatic symptoms, and depression. Baseline measures, anxiety, and the Rome III criteria were assessed in the follow‐up evaluation. Results At baseline, 44.8% of the patients reported significant nausea. Those with nausea reported worse abdominal pain, gastrointestinal symptoms, somatic symptoms, and depression than those without nausea (P < .001 for all). When the children had reached young adulthood, those with nausea in childhood continued to have more severe gastrointestinal (P < .001) and somatic symptoms (P = .003) than patients without nausea in childhood, as well as higher levels of anxiety (P = .02) and depression (P = .02). In the follow‐up evaluation, somatic symptoms, depression, and anxiety remained significant after controlling for baseline abdominal pain severity. Conclusions Pediatric patients with FAP and nausea have more severe short‐ and long‐term gastrointestinal and somatic symptoms than patients with FAP without nausea, as well as reductions in mental health and daily function. Pediatric patients with FAP and nausea therefore need intensive treatment and follow‐up evaluation.

Adolescents’ Observations of Parent Pain Behaviors: Preliminary Measure Validation and Test of Social Learning Theory in Pediatric Chronic Pain

Objective Evaluate psychometric properties of a measure of adolescents’ observations of parental pain behaviors and use this measure to test hypotheses regarding pain-specific social learning. Methods We created a proxy-report of the Patient Reported Outcomes Measurement Information System (PROMIS) Pain Behavior–Short Form (PPB) for adolescents to report on parental pain behaviors, which we labeled the PPB-Proxy. Adolescents (n = 138, mean age = 14.20) with functional abdominal pain completed the PPB-Proxy and a parent completed the PPB. Adolescents and their parents completed measures of pain and disability during the adolescent’s clinic visit for abdominal pain. Adolescents subsequently completed a 7-day pain diary period. Results The PPB-Proxy moderately correlated with the PPB, evidencing that adolescents observe and can report on parental pain behaviors. Both the PPB-Proxy and PPB significantly correlated with adolescents’ pain-related disability. Conclusions Parental modeling of pain behaviors could represent an important target for assessment and treatment in pediatric chronic pain patients.

Brain–gut interactions and maintenance factors in pediatric gastroenterological disorders: Recommendations for clinical care.

Pediatric gastroenterological disorders are frequently encountered by the practicing pediatric psychologist and can be challenging to treat due to the range of presenting symptoms and potentially high impact on patient’s functioning. In this article, the authors aim to (a) describe the brain–gut axis as a means to increase understanding among pediatric psychologists of the biological mechanisms implicated in pediatric GI disorders and how their interactions with psychological and contextual factors maintain GI symptoms and (b) provide practical ways for pediatric psychologists to incorporate the discussion of biological mechanisms and the brain–gut axis into patient education and psychological interventions. Biological mechanisms of the brain–gut axis including alterations in pain processing, the stress response system, and gut microbiome activity will be reviewed. Psychosocial factors that contribute to or maintain disturbances in the brain–gut axis are discussed with implications for clinical assessment and intervention. The authors assert that a mutual understanding by patients, families, and providers alike of the relevant brain–gut interactions and the biopsychosocial model, in general, will serve as a foundation for successful delivery of and adherence to psychological intervention.

Impaired conditioned pain modulation in youth with functional abdominal pain.

Abstract Functional abdominal pain (FAP) is associated with enhanced pain responsiveness. Although impaired conditioned pain modulation (CPM) characterizes adults with a variety of chronic pain conditions, relatively little is known about CPM in youth with FAP. This study assessed CPM to evoked thermal pain in 140 youth (ages 10-17), 63 of whom had FAP and 77 of whom were healthy controls. Multilevel models demonstrated weaker CPM effects in youth with FAP than in healthy youth, as evident in slower within-person decreases in pain ratings during the conditioning phase. Weaker CPM effects were associated with greater somatic symptom severity and functional disability. Pain responses in youth with FAP were heterogeneous, with 43% of youth showing an unexpected increase in pain ratings during the conditioning phase, suggesting sensitization rather than CPM-related pain inhibition. These findings highlight directions for future research on the emergence and maintenance of FAP in youth.

Development of a pediatric psychology practicum for doctoral trainees in the context of outpatient pediatric gastroenterology.

This article demonstrates how the development of a practicum in pediatric psychology in a multidisciplinary clinic provides rich opportunities for doctoral trainees. The process of partnering with a pediatric gastroenterology clinic with limited behavioral health services and developing a practicum that met both clinic needs and trainee goals is described. Initial data assessing utilization, acceptability, and training effectiveness are presented. Medical providers (N = 11) were asked to complete a brief survey to assess their experience with the trainees; graduates of the training clinic (N = 3) were asked to retrospectively rate competencies before and after the training practicum. Preliminary data suggest that pediatric psychology services were well utilized and providers reported high levels of acceptability and satisfaction. Graduates of the training practicum reported growth in each competency. This practicum evolved into a tiered 2-year practicum experience that met core competencies in pediatric psychology across multiple domains. Lessons learned are reviewed in order to guide other graduate programs wishing to develop similar pediatric psychology practicum for advanced doctoral students with interests in pediatric psychology.

Development and Validation of a Nausea Severity Scale for Assessment of Nausea in Children with Abdominal Pain-Related Functional Gastrointestinal Disorders

The objective of this study was to develop a pediatric measure of chronic nausea severity, the Nausea Severity Scale (NSS), and evaluate its reliability and validity in youth with abdominal pain-related functional gastrointestinal disorders (AP-FGID). Pediatric patients (aged 11–17 years-old, n = 236) presenting to an outpatient clinic for evaluation of abdominal pain completed the NSS, Children’s Somatization Inventory (CSI), Functional Disability Inventory (FDI), Abdominal Pain Index (API), Patient-Report Outcomes Measurement Information System (PROMIS), Anxiety and Depression Scales and the Pediatric Rome III Questionnaire for FGIDs. The NSS demonstrated good concurrent, discriminant, and construct validity, as well as good internal consistency. One-third (34%) of AP-FGID patients reported experiencing nausea “most” or “every day” in the previous two weeks. The severity of nausea was higher in females than males and correlated significantly with the severity of somatic symptoms, functional disability, anxiety, and depression. The NSS is a valid and reliable measure of nausea in children with AP-FGID.

Functional Nausea in Children: A Review of the Literature and Need for Diagnostic Criteria

Nausea is common amongst children with functional gastrointestinal disorders and is associated with a high burden of somatic and psychosocial comorbidities in both the short and long-term. Current treatments including medications, phytotherapy, stress-reduction techniques, and gastric electrical stimulation for recalcitrant cases, are reviewed. Functional nausea merits its own diagnostic criteria as a pediatric functional gastrointestinal disorder.